Researchers presented the case report of a patient who had pancytopenia associated with COVID-19 that manifested as paroxysmal nocturnal hemoglobinuria (PNH) and aplastic anemia in Preprints. 

SARS-CoV-2 has been associated with a number of hematological abnormalities, including more recent reports of PNH and aplastic anemia. Although there is debate regarding the causality of this relationship, the authors of the case study felt it was important that such cases were documented and added to the existing medical literature. 

A 21-year-old man presented at the hematology clinic for pancytopenia that was incidentally discovered during a preoperative assessment for ankle open reduction and internal fixation. He had no chronic comorbidities but suffered from a mild COVID-19 infection confirmed via polymerase chain reaction testing. He had no family history of hematological diseases. 

Laboratory investigations conducted during the preoperative assessment revealed a hemoglobin of 9.3 g/dL, a leucocyte count of 4.1 × 103 cells/uL, an absolute neutrophil count of 2.74 × 103 cells/uL, a platelet count of 34 × 103 cells/uL, lactate dehydrogenase of 595 U/L, and total bilirubin of 1.4 mg/dL. A repeat COVID-19 test was negative. 

Read more about PNH etiology 

A bone marrow biopsy was carried out, revealing decreased trilineage hematopoiesis and no blast cells. Cytogenetic studies demonstrated an abnormal 13q deletion in 2 of 20 cells. Finally, flow cytometry revealed 19.53% of PNH clones in granulocytes, 19.77% in monocytes, and 3.61% in red blood cells (0.22% of type 2 cells and 3.39% of type 3 cells). 

In light of these findings, the patient was diagnosed with hemolytic PNH and moderate aplastic anemia. He was started on appropriate immunizations for encapsulated organisms, followed by ravulizumab. After completing 3 doses of ravulizumab 5 months later, he remains transfusion independent and shows improvement in his blood work. 

“It is possible that SARS-CoV-2 does play a role in the development of PNH clonal expansion and bone marrow failure, but the exact mechanism is still unknown,” the authors wrote. “This emerging relationship between COVID-19, aplastic anemia, and PNH is being investigated globally.” 


Aguilar JJ, Dhillon V, Balasubramanian S. Manifestation of pancytopenia associated with COVID-19 as paroxysmal nocturnal hemoglobinuria (PNH) and aplastic anemia (AA)Preprints. Published online August 22, 2023. doi:10.20944/preprints202308.1585.v1