- COVID-19 may potentially represent a novel etiology for ITP, although we cannot exclude other causes of thrombocytopenia in this case (e.g. thrombocytopenia related to amoxicillin–clavulanic acid exposure).
A 65-year-old woman with hypertension and autoimmune hypothyroidism was admitted with COVID-19 pneumonia in Strasbourg, France. Laboratory tests performed at admission showed a normal full blood count (with platelet count at 183,000 per cubic millimeter), an elevated C-reactive protein and abnormal liver-function tests. She was initially treated with intravenous amoxicillin–clavulanic acid, low-molecular-weight heparin and oxygen. On day 4, she developed lower-extremity purpura and epistaxis; isolated thrombocytopenia (platelet count 66,000) was noted, which prompted discontinuation of antibiotics and heparin. The thrombocytopenia progressed over the next few days (with platelet count dropping to 8,000 on day 7), while blood coagulation parameters remained normal (except for a marginally elevated fibrinogen level) and a peripheral blood-smear showed fewer than 1% schistocytes. High titers of anti-TPO antibody were detected, but other serologic tests (antiplatelet factor 4, antiplatelet antibodies, and antinuclear antibodies) were negative. She received intravenous immunoglobulins (IVIG), but the purpuric lesions progressed, and the platelet count reached a nadir of 1000 per cubic millimeter, prompting a second infusion of IVIG. Bone marrow aspiration showed normal cellularity with increased pleomorphic megakaryocytes, without evidence of hemophagocytosis. On day 9, the patient developed a headache without other alarming symptoms, and CT of the head revealed a subarachnoid microhemorrhage in the right frontal lobe; a platelet transfusion was administered with 100 mg of prednisolone, and eltrombopag was initiated. The patient finally showed improvement: the headache resolved, the platelet count progressively increased to 139,000 per cubic millimeter, and the purpura disappeared.
Zulfiqar A.-A., Lorenzo‑Villalba N., Hassler P. and Andrès E. (April 15, 2020). Immune Thrombocytopenic Purpura in a Patient with Covid-19. The New England Journal of Medicine (NEJM). https://doi.org/10.1056/NEJMc2010472