The COVID-19 pandemic, which turned the world upside down over a period of roughly 2 years starting from 2020, was a strange period for medicine. On one hand, it seemed that all of medicine had to sit still while COVID-19 was having its moment; hospitals turned into infection camps, elective surgeries were canceled, and routine appointments were postponed or moved online.
At the same time, the world had a once-in-a-lifetime opportunity to “stress test” its healthcare infrastructures. In the United States, our healthcare structures largely held up. Telemedicine in particular played a role in allowing patients to have continued access to healthcare while minimizing the risk of onsite infection.
Read more about ITP diagnosis
Another subsection of medical literature mushroomed as the pandemic subsided: studies that deal with how various diseases interact with COVID-19. A number of questions were raised: does COVID infection worsen clinical outcomes in patients with chronic diseases? Has care been compromised or reduced during the pandemic? How do we deal with newly diagnosed cases of rare diseases on a background of COVID?
A quick literature search using online academic search engines will reveal the extent that these questions of interest have stirred debate and generated controversies.
At the time of writing, COVID-19 restrictions have been largely lifted in most parts of the world. Whispers of humanity moving into a “post-COVID” era have grown louder. Only in China are full-blown pandemic restrictions still in place. For the rest of the world, now is the time to reflect about the past and prepare for the future.
In this article, we will look at a case report of a patient who contracted COVID-19 while having concurrent immune thrombocytopenia.
SLE and Immune Thrombocytopenia
The case as presented by Alonso-Beato and colleagues in Lupus details a 49-year-old male who presented at the emergency department with cough and myalgias. He was afebrile and did not suffer from any active bleeding. Chest auscultations and radiogram were normal; vitals were stable; oxygen saturation was 97% on air. A polymerase chain reaction (PCR) test was ordered for SARS-CoV-2, which returned positive.
The patient has a known history of systemic lupus erythematosus (SLE), lupus nephritis, antiphospholipid syndrome (APS), and immune thrombocytopenia. For his SLE, he takes mycophenolate mofetil 500 mg every 12 hours, as well as prednisone 5 mg and hydroxychloroquine 200 mg daily. His SLE has been well-controlled and reported to be inactive for the past 5 years.
As for the patient’s APS, the diagnosis was made upon discovery of a deep vein thrombosis and a venous thromboembolism. With regards to his immune thrombocytopenia, the patient revealed that he has suffered with the disease for 20 years, but that acute episodes managed to be resolved with corticosteroids and intravenous immunoglobulin. He has not had an acute episode in years.
Blood investigations revealed low platelet count (30×109/L). His international normalized ratio was revealed to be high as indicated by a value of 2.29.
“Complement was normal and anti-ds DNA antibodies were negative,” the study authors wrote. “Anticardiolipin and anti-beta-2-glycoprotein IgG were positive, with similar titers to those seen during previous follow-up; lupus anticoagulant was not tested due to the previous vitamin K antagonist treatment.”
A Coombs test was ordered and returned negative. His physicians established a diagnosis of immune thrombocytopenia flare, and he was prescribed prednisone 0/5 mg/kg/day. He was discharged and managed as an outpatient with close follow-up. His acenocoumarol was changed to low-molecular-weight heparin until his platelet count recovered.
Ten days later, his platelet count returned to normal, and his physicians ordered that his prednisone be tapered to his previous dose.
Steps Taken
In the event of a pandemic, symptoms such as cough and myalgia are almost always assumed to be the result of a virus unless proven otherwise. In the case of this patient, his positive COVID status allowed COVID protocols to be established before further investigations were conducted.
Under normal circumstances, primary immune thrombocytopenia is a diagnosis of exclusion.
“Recent drug intake, infections, lymphoproliferative disorders, and connective tissue disorders should be ruled out before labeling a patient as primary [immune thrombocytopenia],” Sandal and colleagues wrote in Expert Review of Clinical Pharmacology. “There is no gold standard test for its confirmation.”
In the case of this patient, a prior history of immune thrombocytopenia has already been established. This meant that his physicians could focus on the more urgent issue at hand, ie, treating his COVID infection, which is likely to be the cause for the flareup. The patient’s platelet count, which on presentation was low, normalized after a few days with supportive treatment.
“Even though our patient had a history of [immune thrombocytopenia], it should be noted that his [systemic autoimmune disease] had been inactive for years,” Alonso-Beato et al wrote. “Thus, it seems that SARS-CoV-2 might somehow have a key role in the development of the current episode of thrombocytopenia.”
Although this case was presented in a straightforward fashion, concomitant disease in COVID can have a more complex presentation. Patients with immune thrombocytopenia tend to present with signs of bleeding, with the first-line medication being intravenous immunoglobulin. When coming across a patient with a history of immune thrombocytopenia with signs of an infection, physicians should quickly establish the type (and severity) of the infection involved and pursue strategies that will relieve both illnesses simultaneously.
References
Sandal R, Mishra K, Jandial A, Sahu KK, Siddiqui AD. Update on diagnosis and treatment of immune thrombocytopenia. Expert Rev Clin Pharmacol. Published online March 30, 2021. doi:10.1080/17512433.2021.1903315
Alonso-Beato R, Morales-Ortega A, Fernández FJH, et al. Immune thrombocytopenia and COVID-19: case report and review of literature. Lupus. Published online May 30, 2021. doi:10.1177/09612033211021161
