key: cord-0919822-0chhrs21 authors: Lee, Eun‐Ju; Liu, Xinguang; Hou, Ming; Bussel, James B. title: Immune thrombocytopenia during the COVID‐19 pandemic date: 2021-04-14 journal: Br J Haematol DOI: 10.1111/bjh.17457 sha: 09167654d09627c620bac93de87fad14e3c70e9d doc_id: 919822 cord_uid: 0chhrs21 nan Two patients received steroids alone for exacerbations of known ITP during infection with SARS-CoV-2. Patient 11's platelets dropped from 60-70 to 23 9 10 9 /l two weeks after diagnosis. His platelets improved to 180 9 10 9 /l on prednisone 20 mg daily. Patient 4's platelets dropped from a baseline of 60-70 to 26 9 10 9 /l. She received dexamethasone 40 mg for four days with platelets rising to 105 9 10 9 /l. Five patients (Patients 2, 3, 5, 6, 12) did not modify their ITP treatment despite COVID-19. Three (Patients 2, 3, 6) were on treatment (eltrombopag, steroids, rituximab, respectively). Patient 5 was discharged from the ER with haematology follow-up for platelets 26 9 10 9 /l and Patient 12 was diagnosed with SARS-Cov-2 on routine screening for caesarean section with platelets 94 9 10 9 /l. Patients 3, 4, 6, 8 were hospitalized and received prophylactic anticoagulation with enoxaparin 40 mg SC daily (NYP-WCM) or nadroparin 3 800 U SC daily (SPCH-SDU) without bleeding events. Patient 6 developed deep vein thrombosis (DVT) and pulmonary embolus (PE) despite prophylactic enoxaparin. He received therapeutic heparin and was discharged on apixaban. Patient 2 presented with a new headache due to cerebral venous sinus thrombosis and was discharged on apixaban. Treatments of ITP, ongoing or newly initiated, can impact the course and outcome of SARS-CoV-2. Thrombosis is a major concern in patients with SARS-CoV-2 infection 2,3 and immunosuppression could worsen infection. The American Society of Hematology offers recommendations limited by data to expert opinion 4 for ITP management in SARS-CoV-2 infection. IVIg is not immunosuppressive, rapidly increases platelets, and has anti-inflammatory effects. To avoid prolonged visits and SARS-CoV-2 exposures, home administration (like Patient 1) is useful. Steroids may risk increasing viral susceptibility early in infection; however, published reports and our own experience suggest steroid use does not often lead to worse outcomes in COVID-19. [5] [6] [7] No consensus exists regarding increased severity of COVID-19 infection in patients who have received rituximab or are on other chronic immunosuppressants. [8] [9] [10] Anti-CD20 agents impair humoral responses to de novo infections and vaccines for at least 4-6 months. We agree with avoiding immunosuppressives or rituximab during the COVID-19 pandemic pending reasonable alternatives. 11 We also caution use of splenectomy due to increased thrombotic risk and risk of overwhelming sepsis. The risk of thrombotic events with SARS-CoV-2 is well documented 2,3 and prophylactic anticoagulation is recommended in hospitalized patients including those with ITP. 4, 12, 13 Cases of thrombosis in COVID19-infected ITP patients have been reported, including two patients included in this report. 5,7,14 Patient 6 developed DVT/PE despite prophylactic anticoagulation. Although an advantage of thrombopoietin receptor agonists (TPO-Ras) would be absence of immunosuppression, caution is recommended during the COVID19 pandemic in patients with additional thrombotic risk factors such as post-splenectomy and platelet counts >100 9 10 9 /l (Patient 2). Follow-up information through February 2021 is available for seven patients (Patients 1, 2, 3, 6, 8, 9, 10) . None required hospitalization for recurrent ITP flares. Both patients with presumed new SARS-CoV-2-associated ITP (Patients 8, 10) maintain normal platelet counts without platelet-specific treatment. Patient 8 did not require treatment beyond IVIg and steroids received during hospitalization. Patient 10 was successfully tapered off steroids in October 2020. The starting platelet counts in our 12 patients were somewhat higher than in the 14-patient French series 6 which had a high percentage of de novo cases whereas 10 of our 12 involved pre-existing ITP. As with ITP in the absence of SARS-CoV-2 infection, treatment needs to be individualized. Steroids, IVIg, rituximab, immunosuppressives, splenectomy and TPO-RAs are discussed above and considerations based on experience applicable to SARS-CoV-2 infection emphasized. Ongoing experience continues to be gathered to better inform care to SARS-CoV-2 infected ITP patients. Standardization of bleeding assessment in immune thrombocytopenia: report from the International Working Group Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: an updated analysis Incidence of venous thromboembolism in hospitalized patients with COVID-19 COVID-19 and ITP: Frequently Asked Questions COVID-19 as a cause of immune thrombocytopenia Clinical characteristics, management and outcome of Covid-19-associated immune thrombocytopenia. A French multicenter series COVID-19-associated immune thrombocytopenia Covid-19 in immune-mediated inflammatory diseases -case series from New York Mild course of Coronavirus disease 2019 and spontaneous severe acute respiratory syndrome coronavirus 2 clearance in a patient with depleted peripheral blood B-cells due to treatment with rituximab Persisting SARS-CoV-2 viraemia after rituximab therapy: two cases with fatal outcome and a review of the literature Practical guidance for the management of adults with immune thrombocytopenia during the COVID-19 pandemic COVID-19 and its implications for thrombosis and anticoagulation Pharmacological agents targeting thromboinflammation in COVID-19: review and implications for future research Evans syndrome in a patient with COVID-19