key: cord-0992297-tk20nfl7 authors: Pedro Lobos, B.; Constanza Lobos, S.; Paola Aravena, R. title: IMMUNE THROMBOCYTOPENIC PURPURA ASSOCIATED WITH CORONAVIRUS 19 INFECTION IN AN ASYMPTOMATIC YOUNG HEALTHY PATIENT. date: 2020-09-09 journal: JAAD Case Rep DOI: 10.1016/j.jdcr.2020.08.037 sha: 8db9df9bde00250d52484089f1f455f5167ca15b doc_id: 992297 cord_uid: tk20nfl7 nan Cutaneous findings in patients with Severe Acute Respiratory Syndrome Coronavirus 2 Infection (SARS-CoV-2) are more common every day. It has been described, among others, pseudochilblains, vesicular, urticarial, and maculopapular eruptions. Livedo or necrosis is less common and, most importantly, suggests occlusive vascular disease usually related to severe coronavirus infection [1] . Petechiae/purpuric rash can resemble dengue fever or appear as a morbilliform rash. This rash can spare palmoplantar skin and mucosa or presents with confluent erythematous macules, papules, and petechia in asymmetric peri flexural distribution. It could represent a sign of milder COVID-19 disease in which differential diagnosis includes druginduced or viral rash, and not necessarily a warning sign of thrombocytopenia [2] . Immune thrombocytopenic purpura (ITP) is an unusual form of COVID-19 presentation. In most cases, it appears in the context of an active coronavirus infection with skin petechiae or purpura being the only or more prominent sign of the disease. During the videoconference, he also showed petechial-like lesions in the dorsum of both hands. A day prior to the petechial eruption, he reported gingival bleeding and a buccal hematoma occurring after a dental procedure. He denied respiratory symptoms, fever, anosmia, hyposmia, headache or any other symptoms. Suspecting a COVID-19 related acute platelet disarrangement, he was immediately instructed to stop any physical activity and a full laboratory workup was requested. Tests were normal ranges except for the platelet count who was severely decreased:1000/ µL (reference range, 150,000-400,000/µL). An oropharyngeal swab for SARS-Cov-2 testing was positive. The peripheral film revealed isolated thrombocytopenia without platelet clumps, normal neutrophils, and red blood cells, suggesting idiopathic thrombocytopenic purpura (ITP). Prothrombin time, activated partial thromboplastin times, and fibrinogen level was within the normal range. The renal function was normal. He started treatment with endovenous immunoglobulins (Flebogamma 1 gr/day for 2 days) and thrombopoietin receptor agonists (Revolade 50 mg/day). Corticosteroids use was deferred. The etiological ITP study was negative for HIV, HBV, Anti DNA and lupus anticoagulant. Only ANA was positive: 1/640. The complement within the normal range. The thyroid function was normal. The chest X-ray showed no abnormalities. He evolved in good general conditions, presenting only on the fifth day a mild episode of J o u r n a l P r e -p r o o f headache, which resolved with acetaminophen. Laboratory showed a progressive increase in the platelet count (83,000/ µL) and the purpuric lesions began to disappear, so was discharged on the sixth day. Three months later, the patient is doing very well, with platelet count within the normal range. The temporal sequence, in this case, suggests but does not prove, that Covid-19 was a causal factor in immune thrombocytopenia in this patient. It is well-known that COVID-19 infection can predispose to arterial and venous thrombosis [3] . ITP COVID-19 associated is a rare presentation with very few cases published [4, 5, 6, 7] . Our case is very interesting because it appears in an asymptomatic young healthy patient with no symptoms or signs of COVID-19 infection, showing a severe ITP with an elevated risk of internal bleeding. The rest of the cases had appeared in the context of COVID-19 infection with respiratory illness [4, 6] , except for two cases, one with a moderate decrease in the patient's platelet count but no skin signs of bleeding [5] , and the other one of a young man with only mild symptoms (fever and runny nose) that unfortunately developed an intracerebral hemorrhage [7] . Similar to the other viral infections [8] , SARS-CoV-2 can also trigger ITP. The etiology of COVID-19 related thrombocytopenia could be multifactorial. Maybe a direct effect of SARS-CoV-2 on hematopoietic and bone marrow stromal cells leading to hematopoietic dysfunction and bone marrow growth inhibition or a cytokine storm, which in turn leads to the destruction of bone marrow progenitor cells, both of which result in decreased platelet production. [9] . Alternatively, it can trigger an auto-immune response against blood cells by inducing autoantibodies and immune complex as a consequences of which platelet destruction is augmented. Recently it has been published autoantibodies positives in almost 70% of severely ill J o u r n a l P r e -p r o o f patients with COVID-19 [10] . None of this had a history of systemic autoimmune rheumatic disease, antinuclear antibodies (ANA) were positive in 34.5% of patients, suggesting autoimmune activation. This finding is not surprising, as cytokines present in the cytokine storm, such as interleukin-6, can drive autoinflammatory reactions and also autoimmunity, probably via pre-existing natural B cell clones or molecular mimicry. The possible autoimmune mechanism merits further investigation. During this pandemic, the findings of petechia and purpura have usually been associated to milder COVID-19 infection but this is not always true, so dermatologists must be aware of this warning sign, to promptly rule out COVID-19 associated ITP, a potential life-threatening disease who may also have treatment issues, because corticosteroids usage in these patients is not fully supported. As SARS-CoV-2 is nowadays widespread, we encouraged testing for SARS-CoV-2 in patients suspected of a thrombocytopenic purpura or its relapsing, even in the absence of respiratory symptoms. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases Curaneous signs in COVID-19 patients: A review Prominent changes in blood coagulation of patients with SARS-CoV-2 infection COVID-19 as a cause of immune thrombocytopenia Roghieh Hossienzade, Fatemeh Jafari. (2020) Isolated severe thrombocytopenia in a patient with COVID-19: A case report Immune Thrombocytopenic Purpura in a Patient with Covid-19 Severe Immune Thrombocytopenia Complicated by Intracerebral Haemorrhage Associated with Coronavirus Infection: A Case Report and Literature ReviewPublished online Review: Viral Infections and Mechanisms of Thrombosis and Bleeding Mechanism of thrombocytopenia in COVID -19 patients et alAutoantibodies related to systemic autoimmune rheumatic diseases in severely ill patients with COVID-19. Annals of the Rheumatic Diseases Published Online First: 24