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Hospitalist Sarah Stone, MD, showed up for her dayshift at Sharp Chula Vista one day in late December. The ICU and health center wards were still overflowing with COVID-19 patients. But over the last couple months, she ‘d also seen a growing number of retrieved patients presenting with a myriad of signs: pulmonary emboli, cardiomyopathy, a stunning case of aspergillosis, and those unusual cases of “long COVID,” the patients who simply can’t improve.
She felt great, however 2 weeks after recovering from COVID-19, she had inexplicable bruising on her arm, a petechiae rash on her legs, and her gums were bleeding. When confessed to the emergency situation department, her platelet count of 5000/ mm 3 was a dead free gift of immune thrombocytopenic purpura(ITP).
In Stone’s experience, brand-new and otherwise inexplicable symptoms so quickly post-COVID can’t be written off as a coincidence without some additional factor to consider. She discovered one report with three cases of post-COVID ITP. Kenneth Johnson, MD, the hematologist/oncologist consulting on the brand-new case, informed Stone he ‘d seen one other case of post-COVID ITP just previously that month.
” I was amazed to discover just 3 cases in the literature when we had actually seen three among us in a matter of weeks,” Stone informed Medscape Medical News. Something was missing.
A Missing Link
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ITP is caused by an immune reaction against a patient’s own platelets
” We understand that infections like influenza can cause ITP, so in this light, [COVID-associated ITP] may not be unexpected,” Gerard Jansen, MD, PhD, an internist and hematologist in Rotterdam, Netherlands, informed Medscape Medical News.
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Jansen and his coworkers recorded three cases of post-COVID ITP in May 2020– the report Stone had actually discovered throughout her shift. Two patients established ITP several weeks after COVID-19 and reacted to treatment with corticosteroids and intravenous immunoglobulin G (IVIG).
A deeper dive into the literature discovers extra case reports from India, France, the United Kingdom, Turkey, and one from China as early as January2020 A September 2020 review of ITP secondary to COVID included 23 documents and a total of 45 clients. The review authors keep in mind that more than 70%of cases happened in patients who were over 50 years and 75%had actually had moderate-to-severe COVID infections. The sample size of 45 is too little to definitively explain what’s taking place in the total population.
ITP’s link to COVID gained a media spotlight previously this month after the Miami obstetrician, Gregory Michael, MD, developed ITP days after getting the Pfizer COVID vaccine. In early January, after 2 weeks in the ICU, Michael passed away of a hemorrhagic stroke triggered by the low platelet count.
Pfizer stated in a statement that they are “actively examining” the case, “however we don’t believe at this time that there is any direct connection to the vaccine.” Other specialists have said the timing, especially in a relatively young and healthy guy, suggests a link to the vaccine is possible or perhaps most likely, but results won’t be known until the United States Centers for Illness Control and Prevention completes its examination.
However “it is rather uncommon to die from ITP,” San Diego hematologist Johnson informed Medscape Medical News. In his more than 20 years of practice, he has never had a patient die from the condition.
For his part, Jansen, the hematologist in Rotterdam, said that at this point we just do not understand if there’s a link between the vaccine and ITP. Both infection and drugs are well established causes of ITP, so with that basic mechanism or pathology in mind it makes good sense that COVID and the vaccine might initiate ITP. It would be really hard to show in simply one instance, he said. And considering the millions who have actually thus far received the vaccine without occurrence, and the recognized risks and dangers of COVID-19, “we still recommend to immunize,” he stated.
The Number of Cases Is Ignored
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“We do not understand much about platelet counts in COVID-19 at all,” he stated. It might be that COVID in some way prevents platelet production or that it eliminates existing platelets. Whatever the exact relationship to the virus, Jansen expects that the real number of COVID-related ITP cases is greater than existing price quotes recommend.
One reason it isn’t coming up more frequently, Jansen said, may be because the cause of ITP in COVID clients is difficult to pin down. The coagulation activation by COVID19 infection leading to shared intravascular coagulation (DIC) and subsequent thrombocytopenia.
Tracking and comprehending COVID-associated ITP initially needs the substantial process of removal needed to identify it.
In addition, substance abuse to deal with COVID might be masking COVID-related ITP. “ Dexamethasone is a mainstay of COVID treatment. And it’s how we treat ITP,” Johnson said, which implies physicians may be treating ITP without even registering it. Which’s one hypothesis for why Stone and Johnson didn’t see a case up until 9 months into the pandemic.
Treating COVID-associated ITP likewise has its difficulties, particularly in clients who develop it throughout an acute COVID infection and are at danger for both internal bleeding and thrombosis. The client established a lung embolism and had a falling platelet count. A retrospective look at the case revealed the transfusion “did not increase numbers at all– which recommends ITP,” Jansen said.
That’s why “it is very important to be familiar with this phenomenon,” Jansen stated of COVID-associated ITP. If a transfusion is not successful, think about that the client might have ITP and adjust. Johnson, in San Diego, hasn’t had to treat a client battling both issues at the same time however says the perfect strategy would be to raise platelets with steroids and IVIG and then give the anticoagulant once the platelet count is greater. But truth is seldom ideal. Typically these 2 treatments will have to be offered concurrently because the patient faces two dangerous risks, he stated. “It’s a very tough situation,” he said.
Fortunately is that standard treatments for ITP appear to work for COVID-associated ITP. Stone and Johnson’s 30- year-old patient reacted so well to intravenous steroids that IVIG was unnecessary. She’s now on a slow prednisone taper and keeps platelet counts at 114,000/ mm 3 at her weekly follow-up appointments with Johnson.
On the other hand, Jansen’s 2 other patients, now nearly a year out of treatment, require no extra medication. Among the patients is completely recovered and, though the other still has lower than normal platelet counts, she has no bleeding symptoms and her platelet counts stay stable. Still, Jansen is nervous for more data looking at the platelet counts in every COVID-19 client and to combine findings from existing COVID-associated ITP patients.
For Stone, she states she’s added one COVID-19– associated issue to her belt.
” It’s just a bit daunting. We do not know how bad post-COVID will be,” she stated. “There’s a lot of levels to this disease. Some individuals handle it for so long and some individuals just improve and carry on– we believe … so far.”
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