Immune Thrombocytopenia Can Accompany SARS-CoV-2 Infection

By Will Boggs MD

July 31, 2020

NEW YORK (Reuters Health) - Immune thrombocytopenia (ITP) can be a presenting feature of SARS-CoV-2 infection, according to a pediatric case report.

"Viral testing should be considered in patients with ITP to ensure that the appropriate triaging and isolation precautions occur to prevent further spread of SARS-CoV-2," Dr. Hoi See Tsao of Warren Alpert Medical School of Brown University, Hasbro Children's Hospital, in Providence, Rhode Island, told Reuters Health by email.

Among the established triggers of ITP are viral, immunologic and environmental events. ITP was recently reported in association with COVID-19 in a 65-year-old woman with hypertension and autoimmune hypothyroidism.

Dr. Tsao and colleagues now report the occurrence of ITP in a 10-year-old previously healthy girl who presented to the emergency department with purple lesions in her mouth and new bruises three weeks after a mild illness with two days of fatigue, nonproductive cough and fever in the setting of known exposure to SARS-CoV-2.

She took no medications, had no allergies, and had no family history of hematologic or autoimmune disorders. Her physical exam was remarkable only for petechiae concentrated on her lower extremities, chest, and neck and ecchymoses in the popliteal regions and shins.

Her complete blood count revealed a low white blood cell count (3.9 billion/L) and low platelets (5 billion/L), and RT-PCR testing was positive for SARS-CoV-2.

A respiratory pathogen panel was also positive for rhinovirus/enterovirus and negative for other viruses (including endemic coronaviruses), the researchers report in Pediatrics.

She was admitted to the hematology service, where she was treated with 30 g intravenous immunoglobulin (IVIG; after pretreatment with acetaminophen and diphenhydramine). She was discharged the following morning.

At a telehealth visit two days after being discharged, her rash and oral lesions had improved, but she developed a mild fever, decreased appetite, headache, nausea, two episodes of emesis and abdominal pain likely secondary to IVIG.

Her symptoms had completely resolved by her two-week hematology telehealth follow-up visit, and her repeat complete blood count was normal.

As in this case, platelet counts in acute ITP after a viral illness usually recover spontaneously within weeks to months, but as many as 20% of children with acute ITP develop chronic ITP.

"While we have already learned a great deal about SARS-CoV-2 in the past several months, we have only just scratched the surface in terms of our understanding of sequelae of SARS-CoV-2 infection," Dr. Tsao said. "I therefore encourage all healthcare providers to openly communicate observations or findings in relation to SARS-CoV-2 with each other and with the general public to help us overcome this pandemic."

She added, "During this challenging time of social distancing and mask-wearing, it can be tough to find and maintain connections with each other. Try to be kind to yourself and others. Find different ways to support one another as we work towards a 'new normal.'"

SOURCE: Pediatrics, online July 29, 2020.