Case Presentation: A 23 year-old previously healthy woman presented with a 2-day history of melena, hematemesis, vaginal bleeding, and bleeding gums. She also reported cough, fevers and anosmia. She denied any new medication exposures and had no prior history of bleeding disorders or hematologic disease. Temperature was 37.2° C, heart rate 122, respiratory rate 18, blood pressure 131/78, and SpO2 99% on room air. Oropharyngeal exam was notable for friable mucosal tissue and bleeding. Skin exam was notable for petechiae and ecchymoses scattered throughout. Lungs were clear to auscultation bilaterally. Coronavirus-19 PCR was positive. Complete blood count revealed normal hemoglobin with a platelet count of 4×109/L and mean platelet volume of 13.4 fL (reference range 7-10 fL). Coagulation studies were normal. Peripheral blood smear was without schistocytes and hemolysis labs were unremarkable. The patient was diagnosed with immune thrombocytopenia (ITP) in the setting of COVID-19 infection. She was treated with intravenous immunoglobulin and a course of dexamethasone. Seven days after initiation of therapy, she continued to have severe thrombocytopenia and mucosal bleeding. She was treated with romiplastin on day 5 of hospitalization. Bleeding symptoms subsequently abated, platelet count stabilized and she was discharged home. She received an additional dose of romiplastin in the hematology clinic 5 days after discharge. On day 14 follow up, the patient had a platelet count of 604x 109/L, no further bleeding symptoms and resolution of petechiae.
Discussion: Since emerging as an era-shaping pandemic in 2019, COVID-19 has challenged hospital providers with a number of associated clinical syndromes, including a well-described association with thrombotic events (1). Hospitalists should also be aware, however, of the association between COVID-19 and bleeding problems as well, particularly ITP. ITP is an autoantibody mediated process (2) and has been strongly associated with other viral infections, including CMV, VZV, HCV, HIV (3-6). Several case reports and two case series (7-8) have reported ITP in the setting of acute COVID-19 infection. Tang, et al reported a summary of 38 cases and Bhattacharjee and Banerjee 45 cases. Overlap in the included cases exists between these series, but Tang et al, reported that 79% of patients were over age 50 with no pediatric cases, while Bhattacharjee and Banerjee reported 71% were over age 50 years, with only three patients under 18. Based on these two series, there is a relative paucity of case reports in young and otherwise healthy individuals as we demonstrate in the current case. Both series indicate that the majority of patients have positive clinical response to short courses of glucocorticoids and intravenous immunoglobulins (IVIG). Use of thrombopoietin receptor agonists, as in our case, have also been utilized, but in a smaller cohort of patients.
Conclusions: In conclusion, hospitalist providers should be aware of both thrombotic and bleeding conditions, particularly ITP, associated with acute COVID-19 infection. Recognition of these associations will allow timely and effective treatment for patients affected by this pandemic disease.