Persistent Relapsing Immune Thrombocytopenia Following COVID-19 Infection

Abstract

Immune thrombocytopenia (ITP) is a rare autoimmune disease that presents along a spectrum of disease severity, ranging from asymptomatic thrombocytopenia to potentially life-threatening bleeding complications. Recent case reports and case series suggest that a COVID-19 infection can trigger secondary ITP and may be associated with higher rates of bleeding and lower nadir platelet counts compared to patients with ITP of other etiologies. Multiple ITP relapses have also been described in some COVID-19 patients. We report the case of a 30-year-old otherwise healthy woman who presented to the hospital with fatigue, easy bruising, and a platelet count of 11 x 10 3 /µL. She responded well to our initial treatment with prednisone and intravenous immunoglobulin (IVIG) but experienced a persistent disease course with nine ITP relapses (defined as platelet count <30 x 10 3 /µL) over the next 10.5 months, requiring six additional hospital admissions for acute management as well as long-term maintenance medication adjustments. It is important for clinicians to recognize ITP as a potential complication of a COVID-19 infection and to initiate early therapy to prevent serious bleeding in these patients. Further studies will be needed to understand the natural history, optimal treatment, and prognosis for patients with relapsing COVID-19-associated ITP.

The Roles and Challenges of Advanced Therapies in the Management of Refractory Immune Thrombocytopenia: A Case Report and Review of the Literature

“…With a resolution of symptoms, he relapsed six years following first-line therapy. Several cases of relapse have been reported by different authors, with a patient having one to nine episodes of relapse [9][10][11][12][13]. Therefore, refractory ITP is not only associated with the burden of prolonged therapy's side effects but also a risk of hospital readmission, infection from immunosuppression, life-threatening complications such as upper or lower GI bleeding, stroke, epistasis, and psychological problems such as depression [14].…”

Expertenreport Immunthrombozytopenie – Aktuelle Diagnostik und Therapie

“…COVID-19 und ITP Es gibt mittlerweile zahlreiche Berichte, dass im Rahmen einer COVID-19 Erkrankung eine ITP-Erkrankung neu auftreten kann [105][106][107][108][109][110][111][112][113]. Bei einigen COVID-19 Patient*innen fallen die Thrombozytenwerte bis unter 1'000/µL und zumindest in Einzelfällen sind auch schwere Blutungen, bis hin zu ZNS-Blutungen beschrieben [106,107,109,112].…”

“…Die sekundäre ITP bei COVID-19 tritt typischerweise nicht am Anfang der COVID-19 Erkrankung auf, sondern häufig nach 1 Woche oder sogar erst nach der Erholung ("late-phase" thrombocytopenia) [115]. In den meisten Fällen ist die Immunthrombozytopenie transient und schließlich normalisieren sich die Thrombozytenwerte wieder, es wurden aber auch Rezidive beschrieben, möglicherweise als Zeichen, dass SARS-CoV-2 auch persistierende oder gar chronische Verläufe induzieren kann [108,113].…”

Autoimmune Diseases Affecting Hemostasis: A Narrative Review

“…Similarly, it is likely that in COVID-19, as in other infectious diseases, molecular mimicry, a hyperactive immune system, and the virus itself represents the triad of plausible causal auto-immune events [ 91 , 98 ]. Other auto-immune conditions related to hemostasis and associated with COVID-19 include ITP [ 99 , 100 , 101 ] and TTP [ 102 , 103 ]. In terms of the latter, a large body of data indicates that COVID-19 is often associated with ADAMTS13 deficiency [ 104 , 105 , 106 ]; however, this may often be due to exhaustion of ADAMTS13 reserves due to the associated elevated release of VWF, rather than any immune basis or TTP.…”