ABSTRACT
Background: Patients with immune thrombocytopenic purpura (ITP) under eltrombopag therapy are vulnerable to thrombotic disbalance either by disease and by therapy-related hypercoagulability. Vascular events such as the development of a free-floating carotid thrombus are known rare complications of acute COVID-19 infections due to an endothelial inflammation and underlying hypercoagulable state. New focal neurological symptoms in patients at risk should be immediately followed by angiographic diagnostics and, if necessary, proceed with the appropriate treatment immediately. Case presentation: Here we report a case of a 38-old female with a medical history of ITP and presence of COVID-19 infection presenting an acute sensorimotor hemiparesis of the right side while oneltrombopag therapy. Initial CT angiography revealed a free-floating thrombus of the left carotid artery. At admission, platelet number was significantly increased at 896/nl. After systemic lysis therapy the thrombus was fully dissolved. Follow-up diffusion-weighted imaging revealed multilocular cortical infarction of the left ACM territory. The patient soon recovered and was released with residual mild sensorimotor deficits of the right arm. Eltrombopag was paused at admission, platelet number was quickly normalizing and the patient was discharged with a daily intake of acetylsalicylic acid, eltrombopag in reduced daily dose and weekly control of platelet number for 3 months. Conclusions: This unique case enhances the need for caution in patients at vascular risk who exhibit an acute COVID-19 infection, and discusses thrombocytic derailment under thrombopoietin receptor agonist therapy associated with an acute COVID-19 infection.