ITP with Severe Hemorrhagic Manifestations Associated with COVID-19 – Case Study
There can be numerous causes of newly acquired immune thrombocytopenia (ITP), often being idiopathic. Severe COVID-19 can be associated with ITP manifestations where the standard first-line treatment may not be effective. In life-threatening bleeding situations, adding romiplostim has proven effective, as illustrated by the following case study from authors in Montreal, Canada.
Case Description
A 53-year-old man with controlled hypertension, dyslipidemia, and type 2 diabetes mellitus presented to the doctor with shortness of breath, dry cough, and fever. Initial examinations showed lymphopenia with a normal white blood cell count and normal platelet count (244 × 109/l), elevated creatinine (222 μmol/l), and slightly elevated transaminases. The PCR test was positive for SARS-CoV-2. The patient's condition rapidly worsened with manifestations of acute respiratory distress syndrome (ARDS), requiring rapid intubation with mechanical ventilation. The patient received antibiotics and thromboprophylaxis with unfractionated heparin. The condition was complicated by acute progressive renal failure requiring dialysis and pneumonia positive for methicillin-sensitive Staphylococcus aureus (MSSA).
On the 20th day of treatment, a tracheotomy was performed, which was noted for abnormal bleeding and subsequently developed endobronchial bleeding leading to left lung atelectasis. The platelet count dropped from 311 × 109/l the previous day to 23 × 109/l, while other blood parameters were normal. No cutaneous bleeding manifestations were present. A CT scan of the brain conducted a few days later showed small intraventricular bleeding. There were no signs of hemolysis or other symptoms of microangiopathy, laboratory tests did not correspond to heparin-induced thrombocytopenia or hemophagocytic lymphohistiocytosis, and serology for common infections was negative. Bone marrow aspiration showed no significant abnormalities. Based on isolated severe thrombocytopenia and examination results, the diagnosis of COVID-19-associated ITP was made.
Intravenous immunoglobulins were administered acutely for 2 consecutive days, followed by intravenous dexamethasone over the next 5 days. Due to bleeding, repeated platelet and erythrocyte transfusions were given along with hemostatic tranexamic acid. Due to the non-increasing platelet count, as part of the second-line treatment, the thrombopoietin receptor agonist (TPO-RA) romiplostim was initiated from the 5th day of treatment, and vincristine was administered once. Boluses of methylprednisolone were given between the 10th and 13th days. An increase in platelet count was observed from the 11th day of treatment, reaching 178 × 109/l 14 days after starting treatment.
Conclusion
In this case, COVID-19-associated ITP appeared relatively late after clinically severe respiratory manifestations of the infection. It was accompanied by significant bleeding manifestations and relative resistance to standard first-line treatment with IVIG and corticosteroids. The second-line treatment involving the TPO mimetic romiplostim led to an increase in platelet count to safe levels.
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Source: Lévesque V., Millaire E., Corsilli D. et al. Severe immune thrombocytopenic purpura in critical COVID-19. Int J Hematol 2020; 112 (5): 746–750, doi: 10.1007/s12185-020-02931-9.
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