key: cord-0909283-b9g6bndb authors: Lapietra, Gianfranco; Ferretti, Antonietta; Baldacci, Erminia; Chistolini, Antonio; Santoro, Cristina title: Immune thrombocytopenia management during COVID‐19 pandemic: An Italian monocentric experience date: 2022-03-09 journal: EJHaem DOI: 10.1002/jha2.406 sha: 60c0c15bf0c2cfe8f8abe076cfdc308f165cd670 doc_id: 909283 cord_uid: b9g6bndb Over the last 2 years, different cases of immune thrombocytopenia (ITP) in patients affected by SARS‐CoV2 have been reported. The management of SARS‐CoV2 in subjects with simultaneous or previous ITP can be challenging because of the great involvement of the haemostatic system in this viral infection. In this report, we describe the management and outcome of patients with newly diagnosed (ND), chronic and previous ITP, infected by COVID‐19, referred to the Haematology Institute of University Hospital Policlinico Umberto I in Rome. Steroids + immunoglobulins for ND or relapsed ITP and continuation of home therapy for chronic ITP are advised, although further knowledge is required. Immune thrombocytopenia (ITP) is an acquired immune disorder characterised by a platelet count of less than 100 × 10 9 /L, leading to an increased bleeding risk. It can occur both in children and adults with an incidence of two to five per 100,000 persons in the general population, with a slight female preponderance [1] . The pathogenesis of ITP is not fully understood yet, but it seems to be triggered by environmental factors in subjects with inherited predisposition. All infectious diseases may potentially cause ITP but the main association has been observed with viral agents [1] . Since the start of the novel pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV2), known as COVID-19, different cases of ITP in infected subjects have been reported from all over the world. Most of these reports are describing newly diagnosed ITP (ND-ITP) in COVID-19 patients [2] [3] [4] [5] [6] [7] ; some authors also report subjects with chronic ITP infected with SARS-CoV2, either relapsing or not [8, 9] . ITP patients, in different phases of the disease, were infected by SARS-CoV2. All these subjects had RT-PCR confirmed SARS-CoV2 infection on a nasopharyngeal swab performed between October 2020 and January 2021. Six were males (35.3%) and 11 females (64.7%). The median age was 57 years (range 30-90). At the time of the COVID-19 infection, patients were characterised as follows: three had simultaneous ND-ITP (17.6%) and one chronic patient experienced a first relapse (5.8%) (median platelet count 5.5 × 10 9 /L, range 2-30); seven subjects had chronic ITP on treatment (41.2%) (eltrombopag, n = 5; romiplostim, n = 1; prednisone, n = 1) (median platelet count 48 × 10 9 /L, range 31-99); two cases had stable chronic ITP never treated (11.8%) (median platelet count 72 × 10 9 /L, range 55-90); four subjects had chronic ITP off therapy on follow-up (FU) (23.6%) (platelet count >100 × 10 9 /L; median FU 92.5 months, range steroids + splenectomy, n = 2; steroids + IvIg + splenectomy, n = 2) (Table 1) . Overall, 15 subjects presented either COVID-19 infection-related symptoms (fever, anosmia, dysgeusia, articular pain and mild-tomoderate respiratory distress) or bleedings (bruising, petechiae and epistaxis). In particular, 11 of them had only COVID-related symptoms (1 g/kg) may be necessary if immediate elevation of the platelet count is required to control bleeding [11, 12] . In our patients with ITP-related bleeding symptoms, IvIg and a higher than the recommended dose of steroids were started to obtain a quick response on platelet count. The should be considered and close monitoring of patients should be done [11, 12] . Early thrombocytosis after SARS-CoV2 infection in subjects with chronic ITP on treatment with need for therapy reduction or even discontinuation has been reported in other case series [10] . In our experience, no patients presented with a paradoxical increase of platelets and no symptomatic thrombosis occurred despite the absence of a specific prophylactic therapy. In fact, antiplatelet or anticoagulant prophylaxis was avoided either in hospitalized patients or in homecare ones, except in two already on such therapies. This decision was made also in consideration of the absence of thrombotic risk factors beyond the viral infection. Symptomatic thrombotic complications did not occur even in subjects on treatment with TPO-RAs again confirming the relative safety of these biologic drugs. In conclusion, we would like to highlight the potential implications of our data, which provides an interesting perspective within the cur- Further knowledge would be useful to improve the management of concomitant ITP and COVID-19 infection. Cristina Santoro https://orcid.org/0000-0002-7181-447X American Society of Hematology 2019 guidelines for immune thrombocytopenia Erratum for: Blood Adv Immune thrombocytopenia secondary to COVID-19: a systematic review COVID-19 presenting with immune thrombocytopenia: a case report and review of the literature Clinical characteristics, management and outcome of COVID-19-associated immune thrombocytopenia: a French multicentre series Immune thrombocytopenia (ITP) in a pediatric patient positive for SARS-CoV-2 COVID-19-associated immune thrombocytopenia Frequently relapsing post-COVID-19 immune thrombocytopenia Incidence, characteristics and clinical profile of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in patients with pre-existing primary immune thrombocytopenia (ITP) in Spain Paradoxical effect of SARS-CoV-2 infection in patients with immune thrombocytopenia Mechanism of thrombocytopenia in COVID-19 patients Practical recommendations for the management of patients with ITP during the COVID-19 pandemic Practical guidance for the management of adults with immune thrombocytopenia during the COVID-19 pandemic Antimicrobial prophylaxis in patients with immune thrombocytopenia treated with rituximab: a retrospective multicenter analysis Safety and efficacy of long-term treatment of chronic/persistent ITP with eltrombopag: final results of the EXTEND study Safety and efficacy of self-administered romiplostim in patients with immune thrombocytopenia: Results of an integrated database of five clinical trials Immune thrombocytopenia management during COVID-19 pandemic: An Italian monocentric experience The authors declare no conflicts of interest. All the authors equally contributed to the final version of the manuscript and approved it.