key: cord-1005858-6y4pkwll
authors: Georgy, Josh T.; Jayakaran, Jonathan A. J.; Jacob, Anju S.; Gunasekaran, Karthik; Korula, Pritish J.; Devasia, Anup J.; Iyadurai, Ramya
title: Evans syndrome and immune thrombocytopenia in two patients with COVID‐19
date: 2021-03-09
journal: J Med Virol
DOI: 10.1002/jmv.26906
sha: 7a984daad38b996c1ae962ae8f8290b5c2215357
doc_id: 1005858
cord_uid: 6y4pkwll

The COVID-19 pandemic caused by the SARS-CoV-2 virus, has enveloped the globe with 83 million cases and 1,831,703 deaths worldwide, the time of writing.(1) This article is protected by copyright. All rights reserved.

The COVID-19 pandemic caused by the SARS-CoV-2 virus has enveloped the globe with 83 million cases and 1,831,703 deaths worldwide, at the time of writing. 1 Among the hematological manifestations described, severe and symptomatic thrombocytopenia has been rare. A meta-analysis of 7613 patients found platelet counts to be much lower in patients with severe COVID-19. 2 Here, we report on two patients with COVID-19, one with Evans syndrome and one with immune thrombocytopenia to highlight the rarer hematological manifestations of the disease. As there is an association between thrombocytopenia and higher mortality, early identification and treatment could potentially improve outcomes. Patient 1: A 33-year-old man presented to the emergency department with a 3-week history of gum bleeding, black tarry stools, and reddish spots on the skin. He had no fever, cough, or dyspnea. On examination, he had petechial lesions over the chest, legs, and oral mucosa.

Laboratory investigations revealed severe thrombocytopenia with initial platelet counts of 6 × 10 9 /L. The peripheral smear showed 11 nucleated RBCs per 100 WBCs, poikilocytosis, ovalocytes, and polychromatic cells with no schistocytes. He had leucocytosis (12 × 10 9 /L), anemia (7.5 g/dl), and elevated lactate dehydrogenase 1953 U/L (normal range, 225-460 U/L). Total and direct bilirubin were 1.23 and 0.46, mean corpuscular volume was 86.8 pl, mean corpuscular hemoglobin 28.3 pg, mean corpuscular hemoglobin concentration 32.6%, and reticulocyte count was 13.73% (corrected 6.87%). Direct Coombs test was positive (2+), suggesting immune hemolytic anemia. Within a few hours of admission, the patient complained of sudden-onset headache and developed a generalized tonic-clonic seizure. Computed tomography of the brain showed intracerebral hemorrhage in the right capsuloganglionic region with edema and midline shift. The patient's sensorium worsened rapidly with anisocoria, and he was shifted to the intensive care unit.

Serology for dengue and scrub typhus (common regional causes of thrombocytopenia) were negative. Nasopharyngeal swab reverse- These cases suggest an association between COVID-19, Evans syndrome, and immune thrombocytopenia, based on temporal profile and other etiologies having been ruled out to a reasonable extent.

They also highlight heterogeneity in the hematological manifestations of COVID-19 ranging from asymptomatic thrombocytopenia to life-threatening disease. This is the second case of Evans syndrome with COVID-19 described in the literature to the best of our knowledge. Li et al. 3 The largest series of seven patients with autoimmune hemolytic anemia, without thrombocytopenia, has been described by Lazarian et al. 6 Nearly all patients were treated with steroids, and two required rituximab.

The mechanisms suggested for thrombocytopenia include SARS-CoV-2 entering hematopoietic cells via the CD13 receptors causing aberrant hematopoiesis, 7 immune destruction due to molecular mimicry between platelet membrane components (especially glycoprotein) and

virus antigens, 8 and increased consumption due to endothelial injury and microangiopathy. The commonest mechanism described in the literature so far has been immune-mediated destruction (Table 1) , which was likely the cause in both of our patients as well. It is imperative to anticipate this complication for early diagnosis and initiation of therapy, as mortality is high.

Thrombocytopenia is independently associated with poor outcome in patients hospitalized for COVID-19

Evans syndrome in a patient with COVID-19

Immune thrombocytopenic purpura in a patient with COVID-19

COVID-19-associated immune thrombocytopenia

Autoimmune haemolytic anaemia associated with COVID-19 infection

Mechanism of thrombocytopenia in COVID-19 patients

COVID-19 as a cause of immune thrombocytopenia

Immune thrombocytopenia in a patient with COVID-19

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

Heparininduced thrombocytopenia in COVID-19

Clinical characteristics, management and outcome of COVID-19-associated immune thrombocytopenia: a French multicentre series