Case Study: Persistent Severe Thrombocytopenia in a 61‑year‑old 9/11 First Responder

ABC News – Uncertainty over certification affects possible 9/11‑related illnesses coverage

Summary

A 61‑year‑old retired Nassau county Police Department officer and 9/11 responder now living in Florida presents with severe, persistent thrombocytopenia (platelets ~26 K/µL), mild anemia, and borderline leukopenia, with markedly reduced megakaryocytes on bone marrow evaluation. Autoimmune panels to date have been negative. The working consideration is acquired amegakaryocytic thrombocytopenia (AATP) or a toxin‑associated marrow failure syndrome. The patient is under active hematology care.

This educational case aims to raise awareness about complex hematologic sequelae in 9/11‑exposed populations and to highlight the importance of individualized, evidence‑based evaluation and support.

Clinical background

• Age: 61 years
  

• Occupation/Exposure: Retired police officer; participated in World Trade Center response/recovery with presumed exposure to dust and combustion products.
  

• Current location: Florida.

Key laboratory data (most recent)

• Platelets: 26 K/µL (severely low).
  

• Hemoglobin/Hematocrit: mildly reduced (mild anemia).

  
  

• RBC count: reduced.

• WBC count: slightly below normal.

• MCV: high‑normal/elevated (macrocytosis tendency).

• Differential: relative lymphocytosis.

Interpretation of the labs

• The constellation of thrombocytopenia + low/normal WBC + mild anemia suggests central (marrow) production impairment rather than isolated peripheral destruction.
  

• Elevated MCV raises consideration of B12/folate deficiency, alcohol‑independent macrocytosis, medication effects, or marrow disorders.

Prior evaluation (high‑level)

• Bone marrow: decreased megakaryocytes reported.
  

• Autoimmune testing: multiple panels negative to date (e.g., ANA, ESR/CRP, selected autoantibodies).
  

• Medications: reviewed; no definitive drug‑induced etiology identified to date.

Differential considerations

1. Acquired amegakaryocytic thrombocytopenia (AATP) - severe thrombocytopenia with markedly reduced megakaryocytes and often poor response to ITP- directed therapy.
   

2. Toxin - or exposure related marrow failure - given 9/11 exposure history; certain inhaled/absorbed agents (e.g., benzene and other aromatics) are myelotoxic and have been studied in WTC cohorts.
   

3. Early/occult clonal hematopoiesis or myeloid neoplasm - clonal hematopoiesis (CHIP) and select hematologic malignancies have been reported at increased rates in some WTC- exposed cohorts; serial assessment is warranted.
   

4. Nutritional or endocrine contributors (e.g., B12/folate deficiency, hypothyroidism) - assess and correct if present.
   

5. Other rare inherited or acquired marrow failure syndromes - consider if clinical course/lineage involvement evolves.

A single case cannot establish causality. Association between an individual’s illness and prior environmental exposure requires careful clinical correlation and, for U.S. federal programs, formal certification processes.

Recommended next steps (to be coordinated by treating hematologist)

• Bone marrow cytogenetics/FISH and myeloid next‑generation sequencing to evaluate for clonal processes (e.g., MDS, MPN overlap, cytogenetic lesions).
  

• Serum thrombopoietin (TPO) level and reticulated platelet fraction if available.
  

• Nutritional panel (B12, folate), reticulocyte count, hemolysis labs as indicated.
  

• Repeat autoimmune screen if clinical suspicion changes.
  

• Imaging if splenic sequestration or liver disease is suspected (ultrasound ± CT).
  

• Medication review for potential marrow suppression.

Management to date and options discussed

• Supportive care with bleeding precautions; transfusion thresholds per treating center.
  

• Thrombopoietin receptor agonists (TPO - RAs) may be considered on a case – by - case basis in AATP or marrow failure contexts; responses are variable.
  

• Immunosuppressive therapy (e.g., calcineurin inhibitors; selected cases report response to antithymocyte globulin) has been described for AATP; evidence base is limited to small series/case reports and should be individualized.
  

• Clinical trials are encouraged whenever available.

About apheresis - based therapies

• Therapeutic plasma exchange (TPE) and immunoadsorption are not standard therapies for AATP and have limited evidence in this context. Per expert society guidance, the role of apheresis is established for specific immune‑mediated hematologic disorders (e.g., TTP) but remains uncertain for marrow failure syndromes such as AATP; use should be considered only in specialized settings or trials. Decisions must rest with the treating hematology team.

All decisions about therapy must be made by the patient and their treating physicians.

9/11 Health Programs: Certification and Care

• The WTC Health Program recognizes a list of covered conditions (aerodigestive disorders, many cancers, mental health conditions, etc.). Coverage requires individual certification that a condition is related to 9/11 exposure and meets program policies.
  

• Hematologic malignancies (e.g., leukemia and lymphoma and other myeloid neoplasms, including myelodysplastic syndromes) are recognized as cancers under Program policy. Non - malignant cytopenias like AATP are not currently listed as covered conditions; petitions and evidence reviews can change coverage over time.
  

• Learn more: WTC Health Program – Covered Conditions • Member Handbook

Educational notes and selected references

Amegakaryocytic thrombocytopenia

• Overview and distinctions between congenital and acquired forms: StatPearls -  Amegakaryocytic Thrombocytopenia (2024).

• CAMT cohorts and genetics (MPL/THPO and related pathways): Germeshausen et al., Haematologica (2021); Capaci et al., Haematologica (2023) and PMC (2023 open‑access).

• Acquired AATP case literature and immunosuppressive options: Roy et al., Cureus (2020); Hussain et al., Hospital Practice (2023).

9/11 exposure and hematologic health

• WTC Program overview and covered conditions: CDC/NIOSH WTC Health Program pages and policy documents.

• Cancer in WTC responders: Pooled cohort analysis, JAMA Oncology (2021/2022 update); multiple myeloma signals, JAMA Oncology (2018).

• Clonal hematopoiesis and precursor conditions in WTC‑exposed cohorts: Jasra et al., Nature Communications/PMC (2022); institutional summaries (Vanderbilt 2022).

• Benzene and marrow toxicity: Environmental Health Perspectives classic reviews.

• Apheresis guidance: American Society for Apheresis (ASFA) 2023 guidelines (Journal of Clinical Apheresis); AJKD Core Curriculum 2023.

Links:

• ABC News coverage of this patient’s story (2025)

• CDC WTC Health Program – Covered Conditions

• CDC WTC Health Program – How the Program works & Member Handbook

• JAMA Oncology pooled analysis of WTC cancer incidence (open access on PMC)

• Jasra et al. (2022) High burden of Clonal Hematopoiesis in First Responders (PMC)

• EHP – Benzene hematotoxicity overview

• ASFA 2023 – Guidelines on the Use of Therapeutic Apheresis in Clinical Practice (PubMed overview)

Public - Facing Takeaways

• The WTC Health Program covers many conditions , including blood cancers (leukemia and lymphoma) but non - malignant cytopenias like AATP currently require case – by - case review and are not on the published list.

Disclaimer: This case study is for education and awareness only and does not constitute medical advice. Every clinical decision should be made by the patient’s treating team.

ImmunoCare does not provide emergency services or determine federal program eligibility.