thrombocytosis is commonly seen in clinical practice and often the cases reported are incidental . the differential diagnosis for thrombocytosis is broad and the diagnostic process can be challenging . in general , causes of thrombocytosis can be described as spurious , reactive , or clonal in nature .
a number of population studies have examined the degree of thrombocytosis as well as the frequency of various etiologies of thrombocytosis when it occurs .
reactive causes are by far the most common etiology of thrombocytosis in these population studies , comprising 8897% of cases in adults in two large case series and 100% of pediatric cases in a single case series .
extreme thrombocytosis , defined as a platelet count > 1,000  10/l is quite rare , as only 25.8% of patients demonstrate this degree of thrombocytosis upon presentation .
although often thought to be more common in clonal processes , extreme thrombocytosis can also be due to reactive causes , with 82% of cases of extreme thrombocytosis in one series being reactive in nature .
a 26-year - old male patient was scheduled for surgery of right indirect inguinal hernia with right sided encysted hydrocele of the cord .
the preoperative laboratory tests reported normal coagulation and biochemical parameters , haemoglobin values of 15.1 g% , no leukocytosis and a platelet count of 2.60 lakhs / cumm .
patient was operated , right sided mesh hernioplasty with excision of hydrocele of the cord was done .
there were no adverse incidents during surgery , the patient was smoothly extubated in the surgery room and transferred to the post anaesthesia care unit .
a routine postoperative analytical blood control was performed , showing high platelets count ( 1,100,000/cumm ) , hemoglobin 11.6 mg / dl and leukocytes 18,400/cumm , with normal values of coagulation and biochemistry tests .
another blood analysis was extracted to verify these data , which again returned a high platelet count ( 1,300,000/cumm ) .
we suggested monitoring platelet count throughout the postoperative period by serial analytical , with introduction of thromboembolic prophylaxis and control of bleeding in the face of the probability of some degree of platelet dysfunction .
the immediate period after surgery was uneventful and the patient was discharged to the ward with hemodynamic stability .
later , on the next postoperative day , patient developed huge scrotal haematoma with ecchymosis around the incision line .
scrotal haematoma was explored , clots were drained , but no obvious bleeder could be identified .
postoperative antithrombotic prophylaxis and bleeding monitoring were maintained until the patient was discharged after 2 weeks of admission , to follow up with outpatient treatment .
analytical blood controls showed that the platelet count was down to normal in 20 days .
thrombocytosis is an incidental finding in 3550% of cases and determination of the cause creates a diagnostic challenge .
the causes of thrombocytosis can be described as spurious , reactive , or clonal in nature as shown in table 1 .
causes of thrombocytosis the reactive thrombocytosis , also called secondary thrombocytosis is the most common type and appears after acute inflammatory , infectious , neoplastic and stress processes . in these scenarios
the levels of thrombopoietin , interleukin-6 and catecholamines are very high , and are thought to be responsible for the increased number of platelets .
it is always necessary to distinguish between clonal ( also known as primary or essential thrombocytosis ) and reactive ( or secondary ) thrombocytosis , because their treatment and prognosis differ .
distinguishing clinical features for primary and secondary thrombocytosis although the diagnostic tests to differentiate essential and reactive thrombocytosis are not easy to perform , laboratory tests that show increased acute phase reactants such as c - reactive protein , fibrinogen , erythrocyte sedimentation rate and interleukin-6 may be useful in the diagnosis of reactive thrombocytosis .
it is accepted that upto 1,000,000 l platelets level are a benign condition , although it remains unclear if these findings are associated with an increased postoperative thromboembolic or haemorrhagic risk .
prophylactic treatment with platelet inhibitors in these situations is controversial , although some authors do consider management of low - dose acetylsalicylic acid appropriate .
reactive thrombocytosis is generally felt thought to be a self - limited process which resolves with resolution of the underlying disorder when possible .
the risk of thrombotic complications with reactive thrombocytosis is felt to be low , as 1.6% of patients with reactive thrombocytosis had thrombotic complications in one large case series .
all of these thrombotic events were venous in location and occurred in patients with other risk factors ( postoperative setting or underlying malignancy ) . even in cases of extreme reactive thrombocytosis
the appearance of thrombocytosis after surgery needs to be diagnosed to establish the type of thrombocytosis ( clonal or reactive ) , as treatment and prognosis are quite different between them . and at all times , the surgeon must remain vigilant due to the possible risk of bleeding or thromboembolic complications .
the work described in this paper was supported jointly by department of pathology and department of surgery , himsr , new delhi .
the authors would like to thank hamdard institute of medical sciences for the administrative support .
the authors also thank the editor and the reviewers for their valuable comments and suggestions that have led to the substantial improvement of the paper .
the work described in this paper was supported jointly by department of pathology and department of surgery , himsr , new delhi .
the authors would like to thank hamdard institute of medical sciences for the administrative support .
the authors also thank the editor and the reviewers for their valuable comments and suggestions that have led to the substantial improvement of the paper .
 thrombocytosis is often an incidental finding seen in 3550% of cases and the cause determination creates a diagnostic challenge . 
 extreme thrombocytosis is rare and seen in 25.8% patients only . among the various causes of increased platelet count , 
 surgical procedures have attracted much attention in both experimental and clinical domain . 
 the appearance of thrombocytosis after surgery needs to be diagnosed to establish the type of thrombocytosis ( clonal or reactive ) , as treatment and prognosis are quite different between them . 
 this case report is vital because of two reasons : first , the increase in platelet count is difficult to rationalize than many of the other thrombocytoses , such as those related to primary augmentation of the function of the bone marrow ; second , the association of platelets with the clotting process has led to the belief that their increase after a surgical procedure is connected with the occurrence of postoperative thrombosis . 
 this case presents an interesting finding from a patient who has undergone major abdominal surgery and has shown an unexpected perpetual increase in platelet count . 
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