SEVERE/REFRACTORY IMMUNE THROMBOCYTOPENIA IN MILD COVID-19 DISEASE

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Severe thrombocytopenia has been shown to be associated with poor prognosis in COVID-19 disease (1). Thrombocytopenia seen in COVID-19 is most likely due to autoimmune destruction or thrombotic consumption and cytokine release (1). Limited literature is available on the management of COVID-induced thrombocytopenia (1). CASE PRESENTATION: A 40 year old male, smoker, with past medical history (PMH) significant for gastroesophageal disease (GERD) presented to the emergency department with a one day history of new onset petechial rash and epistaxis. His rash appeared distally on his legs and progressed proximally up to his torso and head. He had minor upper respiratory tract (URI) symptoms for three days prior to the onset of rash and epistaxis. He received Mucinex for his URI. He had no history of bleeding disorder. He had a family history of factor V Leiden deficiency in his maternal grandfather and aunt. He had no fever, chest pain, shortness of breath and cough. He was found to be COVID positive with a platelet count of 4000. His vital signs were stable. He had clear lungs on presentation and throughout his hospital stay. His hepatitis panel was negative. He had no findings of disseminated intravascular coagulation (DIC). His vitamin B12 and folate levels, ANA screen and rheumatoid screen were within normal limits. His CT Scan of Abdomen with IV contrast was negative for splenomegaly. His Chest X ray was normal. His flow cytometry analysis showed no evidence of lymphoproliferative disorder. He received one unit of platelets and a four day empiric treatment with steroids. His platelet count improved to 70,000 on the day of discharge (day 4). Nine days after discharge, he was found to have recurrent thrombocytopenia with a platelet count of 17,000. He received intravenous IV immune globulin (IVIG) along with a 35 day taper of prednisone started at a dose of 50mg once daily. His platelet count continued to remain near 35,000 suggestive of steroid-refractory thrombocytopenia. He was started on a weekly regimen of Rituxan. His platelet count continued to remain below 100,000. His treatment is monitored and ongoing. DISCUSSION: COVID-19 associated thrombocytopenia is proposed to have various mechanisms in different phases of disease in diverse patients (1). The causal relationship between COVID-19 and immune thrombocytopenia (ITP), although well studied, has not been established (2). The majority of patients with COVID-19 and ITP have responded to high dose IVIG (1). CONCLUSIONS: Our patient had severe ITP due to COVID-19 despite having mild disease. He had steroid and IVIG-refractory thrombocytopenia. Further research in areas such as the effect of anti-TPO antibodies and splenectomy on these patients is warranted. REFERENCE #1: Murt A, Eskazan AE, et.al. COVID-19 presenting with immune thrombocytopenia: a case report and review of the literature. J Med Virol. 2021;93(1):43-45. REFERENCE #2: Zong X, Gu Y, Yu H, Li Z, Wang Y. Thrombocytopenia Is Associated with COVID-19 Severity and Outcome: An Updated Meta-Analysis of 5637 Patients with Multiple Outcomes. Lab Med. 2021;52(1):10-15. DISCLOSURES: No relevant relationships by Sathyanarayana Machani, source=Web Response No relevant relationships by Edward Marks, source=Web Response No relevant relationships by Trishala Menon, source=Web Response No relevant relationships by Irvin Richard, source=Web Response No relevant relationships by Bradley Schmitt, source=Web Response