key: cord-0770913-ib4g18gw
authors: Soares, Ana Cláudia Carramaschi Villela; Loggetto, Sandra Regina; Manga, Fernanda Cristina Marinho; Faustino, Laira Rita; Braga, Josefina Aparecida Pellegrini
title: Outcome of SARS-CoV-2 and immune thrombocytopenia in a pediatric patient
date: 2020-09-23
journal: Hematol Transfus Cell Ther
DOI: 10.1016/j.htct.2020.09.145
sha: 561c8488257cc1b0a4ec8d05bbe82de9d8fc569c
doc_id: 770913
cord_uid: ib4g18gw

nan

The published data have focused on severe respiratory manifestations, found predominantly in adults, while in children the clinical manifestations are mostly asymptomatic and mild. When the disease is more severe in children, it occurs more frequently in those with less than one year of age or with preexisting illnesses. 1 Hematological changes are frequent in the COVID-19 disease, such as early lymphopenia and, as the disease progresses, anemia and neutrophilia. 2 Thrombocytopenia can occur secondary to sepsis, disseminated intravascular coagulation or drug-induced, 3 as well as direct bone marrow suppression or immune-mediated destruction. 4 We report the case of a previously healthy child infected with SARS-CoV-2 who developed thrombocytopenia at two different times: during the acute infection and later, as immune thrombocytopenia (ITP), with complete response to intravenous immunoglobulin (IVIG).

A previously healthy two-year-old girl developed fever and bruises on her lower limbs, with no other clinical manifestations. Her platelets were 56,000/mm 3 , leukocytes, 3,100/mm 3 , neutrophils, 930/mm 3 , lymphocytes, The antinuclear factor was non-reactive. Therefore, the diagnosis of newlydiagnosed ITP was made. After eight days, the bruises and the petechiae increased and platelets were at 16,000/mm 3 . She was admitted to the hospital to collect bone marrow aspirate and to receive IVIG at a programmed dose of 1g/Kg/day for two days (D33).

The bone marrow aspirate showed megakaryocytic hyperplasia and normocellularity of the erythrocytic and granulocytic series ( Figure 1 ). The RT-PCR for SARS-CoV-2 was negative and the serology for SARS-CoV-2 revealed negative IgM and positive IgG. After 48 hours of IVIG, the platelet count was 108,000/mm 3 (D35). After five days (D40), the platelet count normalized (447,000/mm 3 ), remaining normal until the D73 (D40 after IVIG) control, showing complete response to IVIG. On D87 she presented a runny nose and sneezing and on D90 (D57 after IVIG), the blood cell count revealed 97,000/mm 3 platelets and atypical lymphocytes. No ITP treatment was J o u r n a l P r e -p r o o f administered, as there was no bleeding. The laboratory tests are described in Table 1 .

The Research Ethics Committee approved the case report and the Informed Consent Form was signed by the parents. Clinical and laboratory data were obtained from the patient's medical record.

Systematic review of 7,780 pediatric patients with COVID-19 did not find bruises, petechiae, thrombocytopenia or neutropenia as disease manifestations. 5 Therefore, the patient presented a clinical condition different from the usual, reporting skin bleeding as the initial symptom, with thrombocytopenia and neutropenia appearing as laboratory test results. As already described in the literature for most symptomatic pediatric cases with COVID-19, the clinical and laboratory manifestations are mild, 1,3 as observed in the reported patient. The purpose for the hospitalization was to treat ITP.

In adults, initial thrombocytopenia is more common, being related to a worse prognosis and occurring relatively frequently in cases requiring hospitalization for SARS-CoV-2. Thrombocytopenia in the late stage of the disease, 14 days after the onset of symptoms, is less frequent (11.8%) and

lasts for approximately seven days, being in most cases transient. 6 In the reported case, three weeks after the diagnosis of COVID-19, the In our case, as the child had a recent SARS-CoV-2 infection, whose hematological consequences are still poorly known in the pediatric population, we chose to perform the laboratory investigation and IVIG, with a complete response, maintaining a normal platelet count up to the D40 control after IVIG.

The new thrombocytopenia after 2 months was not due to the loss of response to IVIG, but probably, to the new viral condition. In pediatric ITP, once the illness is resolved, signs of recurrence are possible, especially following another viral illness or antigen exposure, and the management of recurrent episodes is the same as that for newly-diagnosed cases. 8 Until now, we found only one report of the occurrence of ITP after SARS-CoV-2 infection in a 10-year-old child, with a good response to treatment with IGIV. The ITP also occurred three weeks after infection by SARS-CoV-2, with petechiae on palate, lower limbs, chest and neck. The blood count had leukopenia, mild neutropenia and significant thrombocytopenia (5,000/mm 3 ). 9 More reports on cases of COVID-19 and ITP in adults have been published. 3 

Hematological findings and complications of COVID-19

COVID-19-associated immune thrombocytopenia

Mechanism of thrombocytopenia in COVID-19 patients

COVID-19 in 7780 pediatric patients: A systematic review Eclinicalmedicine

Delayed-phase thrombocytopenia in patients with coronavirus disease 2019 (COVID-19)

Guidelines on the treatment of primary immune thrombocytopenia in children and adolescents: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular Guidelines Project: Associação Médica Brasileira -2012

Idiopathic thrombocytopenic purpura: a 10-year natural history study at the Children's Hospital of Alabama

Immune thrombocytopenia (ITP) in a SARS-CoV-2-positive pediatric patient

Thrombocytopenia as an initial manifestation of COVID-19; case series and literature review

Diagnosis and management of typical, newly diagnosed primary immune thrombocytopenia (ITP) of childhood

We thank the patient and her parents for their willingness to share this case report.J o u r n a l P r e -p r o o f