TOPIC: Critical Care TYPE: Global Case Reports INTRODUCTION: Immune thrombocytopenia (ITP) has been associated with COVID-19. We present a case of a patient with COVID-19 who developed severe ITP associated with fatal hemorrhage. CASE PRESENTATION: A 50-year-old-female with history of treated breast and renal cancers presented to the emergency department with cough and fever for 10 days. Nasopharyngeal swab was positive for SARS-CoV-2. The patient was administered supplemental oxygen and empiric broad spectrum antibiotics. Her respiratory status rapidly declined necessitating invasive mechanical ventilation and admission to the ICU on Day 1 for severe ARDS. IV Remdesivir, Dexamethasone 6 mg IV daily, convalescent plasma and IV unfractionated heparin infusion were administered. Platelets were 219 x 109/L, fibrinogen 980 and D-dimer level 11.2. On Day 18 platelets fell to < 2 x 109/L, without evidence of schistocytes on peripheral blood smear. Coagulation and liver function tests, and autoimmune disease markers were normal. Heparin was discontinued. Anti-platelet factor 4 heparin antibodies and platelet autoantibodies were not detected. ITP secondary to COVID-19 was considered and methylprednisolone 1 mg/kg IV and IV immune globulin (IVIG) daily for 5 days and platelet transfusions to keep platelets >5 x 109/L were administered with improvement in platelets to >150 x 109/L on Day 23. On Day 25, platelets decreased to < 2 x 109/L, with melena and leg petechiae requiring red cell and platelet transfusions. She was re-treated with IVIG for 5 days, dexamethasone 40 mg IV daily and Romiplostim 2mcg/kg subcutaneous weekly with rise in platelets to >150 x 109/L on Day 31. She remained ventilator dependent and underwent tracheostomy on Day 32. Platelet counts remained >200 x 109/L and Romiplostim was discontinued on Day 73. On Day 85, platelets again fell to < 5 x 109/L, associated with massive gastrointestinal hemorrhage and fatal hemorrhagic shock. DISCUSSION: We believe that severe ITP with multiple relapses associated with COVID-19 was the most likely cause of the significant drop in platelet count that caused significant bleeding and death in our patient. We also observed a delayed onset in the clinical presentation of ITP and symptomatic COVID, unlike previous reports. The initial episode of severe thrombocytopenia was responsive to glucocorticoids and IVIG and later required higher doses of steroids and Romiplostim but recurred upon discontinuation of therapy. Fatal hemorrhage due to COVID-19-associated ITP is rare. A review of 45 cases of ITP in COVID-19 patients reported the majority of cases (75%) occurring in moderate-to-severe COVID-19. Severe life-threatening bleeding was uncommon with one death attributed to intracranial hemorrhage. CONCLUSIONS: Clinicians need to be aware of ITP as a severe complication of COVID-19 that should be diagnosed and treated promptly to avoid fatal bleeding complications, as was observed in our patient. REFERENCE #1: Bomhof G, Mutsaers PGNJ, Leebeek FWG, et al. COVID-19-associated immune thrombocytopenia. Br J Haematol. 2020 Jul;REFERENCE #2: Mahévas M, Moulis G, Andres E, et al. Clinical characteristics, management and outcome of Covid-19-associated immune thrombocytopenia. a French multicentre series. Br J Haematol. 2020 Aug;190(4):e224-e229. REFERENCE #3: Bhattacharjee S, Banerjee M. Immune thrombocytopenia secondary to COVID-19: a systematic review. SN Comprehensive Clinical Medicine 2020 DISCLOSURES: No relevant relationships by Alina Dulu, source=Web Response Advisory Committee Member relationship with Jazz Pharmaceuticals Please note: $1-$1000 by Stephen Pastores, source=Web Response, value=Consulting fee Grant Support for Clinical Trial relationship with Biomerieux Please note: $5001 - $20000 by Stephen Pastores, source=Web Response, value=Grant/Research Support No relevant relationships by Katherine Silvey, source=Web Response No relevant relationships by Kate Tayban, source=Web Response
SEVERE REFRACTORY IMMUNE THROMBOCYTOPENIA IN AN ONCOLOGY PATIENT WITH COVID-19: RARE BUT FATAL!