COVID-19-ASSOCIATED THROMBOTIC THROMBOCYTOPENIC PURPURA: A FATAL NIGHTMARE

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID-19 virus has been reported to be associated with many unusual conditions and coagulopathies including thrombotic microangiopathies, DVTs, and PEs. However, cases of COVID 19 associated TTP are very rare. We discuss a patient with confirmed COVID-19 pneumonia who then developed acquired autoimmune TTP. CASE PRESENTATION: A 68-year-old female with no significant past medical history presented to the hospital with generalized weakness, shortness of breath, and cough. The onset of symptoms was about 7 days. Initial labs were significant for positive COVID-19 on PCR, WBC 10.4 k/ul, Lactic 1.3, D-dimer 3109 ng/ml. Chest x-ray revealed diffuse bilateral pulmonary infiltrates. She was placed on high flow oxygen with saturation between 80 - 89%. Remdesivir, Dexamethasone & one unit of COVID Convalescent Plasma were started for COVID-19 pneumonia. On day 2, she was switched to BIPAP due to worsening respiratory distress. On day 3, she was intubated due to rapidly progressive ARDS. Blood cultures were negative. She developed neutrophil predominant leukocytosis and anemia. On day 5, she developed thrombocytopenia. On day 8, her platelet counts declined to 17,000. Peripheral smears showed minor areas of clumping while platelet still significantly decreased. Redraw with citrate tube showed no major difference in platelet count. Testing showed evidence of hemolysis with undetectable haptoglobin, rising bilirubin level, and markedly elevated LDH with worsening renal functions. Directs Coombs test was IgG positive with abundant schistocytes on smear. PLASMIC SCORE 7 indicating a high risk for ADAMTS 13 deficiency. The patient was started on high dose IV steroids and needed a total of 2 units of packed red blood cell, 7 units of platelets, and 27 units of fresh frozen plasma. Her condition continued to deteriorate, and she was transferred to a tertiary care center that has plasmapheresis capability. Unfortunately, the patient died a few days later despite treatment. DISCUSSION: There have been only few cases in the literature discussing TTP involvement with COVID-19 infection. A case series and a four patient mini-review of this association were published in January 2021. COVID-19 seems to be the primary trigger. Autoimmunity and endothelial damage could be important factors in these manifestations. Plasmapheresis seem to improve this condition. However, due to the low population of patients, more cases are needed to draw a conclusion and better understand the presentation of COVID-associated coagulopathy. CONCLUSIONS: This case highlights the importance of evaluating and recognizing the hematological complication associated with COVID-19. Therapeutic plasma exchange and IV steroids should be started early. Rapid progression if not treated promptly. Further studies are needed to understand pathogenesis, clinical course, and proper management. REFERENCE #1: George JN, Nester CM. Syndromes of thrombotic microangiopathy. N Engl J Med. 2014 Nov 6;371(19):1847-8. doi: 10.1056/NEJMc1410951. PMID: 25372103. REFERENCE #2: I ba, T., Levy, J.H., Connors, J.M. et al. The unique characteristics of COVID-19 coagulopathy. Crit Care 24, 360 (2020). https://doi.org/10.1186/s13054-020-03077-0 REFERENCE #3: Tehrani HA, Darnahal M, Vaezi M, Haghighi S. COVID-19 associated thrombotic thrombocytopenic purpura (TTP) ; A case series and mini-review. Int Immunopharmacol. 2021 Apr;93:107397. doi: 10.1016/j.intimp.2021.107397. Epub 2021 Jan 22. PMID: 33524803; PMCID: PMC7825972. DISCLOSURES: No relevant relationships by Musa Abu-Jubara, source=Web Response No relevant relationships by Dania Abu-Jubara, source=Web Response No relevant relationships by Adebayo Fasanya, source=Web Response