key: cord-0825528-xbpjkdcj
authors: Serrano, Claudia; Español, Ignacio; Cascales, Almudena; Moraleda, José M.
title: Frequently Relapsing Post-COVID-19 Immune Thrombocytopenia
date: 2021-07-20
journal: SN Compr Clin Med
DOI: 10.1007/s42399-021-01019-7
sha: f63a1b99d2e53fe20ad2613023e08211f774edf6
doc_id: 825528
cord_uid: xbpjkdcj

nan

ITP. Methylprednisolone 1 mg/kg/day was started, with an initial response (44 × 10 9 /L platelets). After 2 weeks of treatment, she was readmitted due to severe thrombocytopenia (6 × 10 9 /L platelets). She was treated with 4 doses of rituximab 375 mg/m 2 /week i.v. and high intravenous doses of unspecific immunoglobulins (IVIg, 1 g/kg/day i.v. for 2 days), without response. Therefore, the patient received dexamethasone (40 mg/day for 4 days), reaching a platelet complete response (116 × 10 9 /L platelets), and was discharged home. One week later, the patient was admitted again with severe thrombocytopenia (5 × 10 9 /L), requiring a second pulse of dexamethasone, IVIg, a fourth weekly dose of rituximab and oral thrombopoietin analogues (eltrombopag 50 mg/day), reaching a platelet count of 102 × 10 9 /L in 6 days. On 19/2/21, she presented with a new decrease in platelet counts (2 × 10 9 /L), spontaneous hematomas on her arms and multiple petechiae on her legs. She received again IVIg, eltrombopag was increased to 75 mg/day and a third pulse of dexamethasone was administered. A new complete response was reached (179 × 10 9 /L platelets). Two weeks later, the number of platelets decreased to 78 × 10 9 /L and a sixth line of treatment with mycophenolate mofetil 1 g b.i.d. was started. Since then, the patient has maintained a platelet count around 60 × 10 9 /L with no clinical haemorrhages or apparent side effects. Patient 2 is a 74-year-old man, living in a care home due to severe mental retardation, who was diagnosed with a mild COVID-19 infection in November 2020 (detected by PCR on 6/11/20, with positive IgG antibodies on 22/11/20 and negative PCR since 26/1//21). Two months later, in January 2021, he presented with epistaxis and melenic stools. The SARS-CoV-2 PCR was negative, but the platelet count was 6 × 10 9 /L, refractory to platelet transfusions. Bone marrow studies were normal (Table 1) . A folic acid deficiency was detected and treated without platelet improvement.

Endoscopic tests were ruled out due to the patient's baseline situation. Other causes of thrombocytopenia were excluded (Table 1 ) and a post-COVID-19 ITP was diagnosed. The patient received IVIg (1 g/kg/day for 2 days) achieving a quick platelet complete response. In February 2021, the patient was admitted again due to severe thrombocytopenia (6 × 10 9 /L) and treated with intravenous IVIg and dexamethasone 40 mg/ day for 4 days, and achieving a second complete platelet response. In March 2021, the patient was readmitted with severe thrombocytopenia and self-limited upper gastrointestinal bleeding. Combined treatment with IVIg and eltrombopag 50 mg/day was started, without alteration of liver function test, and a third maintained platelet complete response was observed.

Most COVID-19-associated ITP patients have been detected during COVID-19 infection [1] . In those cases, the use of corticosteroids as first-line treatment is recommended, due to the risk of thrombosis related to thrombopoietin analogues. On the contrary, thrombopoietin analogues are considered first-line in COVID-19-negative ITP patients, due to the risk of immunosuppression associated with corticosteroids [6] . Post-COVID-19 infection ITP is a rarely described type of ITP, without treatment guidelines [1, 4] . Herein, we report two adult cases observed 4 and 8 weeks after a mild COVID-19 infection. Both patients presented with bleeding manifestations as well as anti-SARS-CoV-2 IgG antibodies and negative PCR tests at the time of ITP diagnosis. In previously reported cases, standard treatment with glucocorticoids and IVig has been effective in achieving a rapidly response [5] . Similarly, our patients had initial responses, but shortlived and followed by recurrent relapses that needed additional treatment strategies. A diagrammatic presentation of treatment offered to our post-COVID-19 ITP patients has been given in Fig. 1 . This atypical clinical course with bleeding signs and frequent relapses in post-COVID-19 ITP should be confirmed with further reports and points out the necessity of basic studies to ascertain the pathophysiology of post-COVID-19 ITP. Our case series show that clinicians should continue follow up of recovered COVID-19 patients so that long-term effects could be uncovered of this novel virus. 

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