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1.
Rinsho Ketsueki ; 62(12): 1688-1693, 2021.
Article in Japanese | MEDLINE | ID: covidwho-1622835

ABSTRACT

A 95-year-old male developed general subcutaneous petechiae, tongue hematoma, and melena two days after receiving the second BNT162b2 mRNA COVID-19 vaccine. Two days later, his platelet count decreased to below 1,000/µl. Laboratory testing was positive for a slight increase in D-dimer, Helicobacter pylori (H. pylori) immunoglobulin G (IgG) antibody, lupus anticoagulant, and anticardiolipin IgG antibody levels. There were no severe infections or symptomatic thrombosis. Platelet transfusions were transiently effective. He was diagnosed with newly developed immune thrombocytopenia (ITP). We administered prednisolone (PSL) at 0.5 mg/kg/day and intravenous immunoglobulin (IVIG) at 0.4 g/kg/day. From the following day, his platelet count rapidly increased, with an improvement in bleeding tendency. H. pylori was eradicated after platelet count recovery. Thrombocytopenia did not relapse although PSL was tapered three months later. Causes of thrombocytopenia after SARS-CoV-2 vaccination include ITP, vaccine-induced immune thrombotic thrombocytopenia, and thrombotic thrombocytopenic purpura. Differential diagnosis is important to determine the proper therapy. Case reports of newly diagnosed ITP after SARS-CoV-2 vaccination have been increasing recently. In these cases, including ours, the responses to steroids and IVIG were good. Further follow-up studies are needed to manage thrombocytopenia following SARS-CoV-2 vaccination.


Subject(s)
COVID-19 , Purpura, Thrombocytopenic, Idiopathic , Purpura, Thrombotic Thrombocytopenic , Aged, 80 and over , COVID-19 Vaccines , Humans , Male , Purpura, Thrombocytopenic, Idiopathic/diagnosis , RNA, Messenger , SARS-CoV-2 , Vaccination/adverse effects
3.
BMJ Case Rep ; 14(11)2021 Nov 05.
Article in English | MEDLINE | ID: covidwho-1503863

ABSTRACT

Immune thrombocytopenic purpura (ITP) is characterised by isolated thrombocytopenia which may be idiopathic or due to a secondary aetiology. ITP is being increasingly recognised secondary to SARS-CoV-2 infection in the current pandemic. Here, we report a case of a five-and-a-half-year-old female child on maintenance chemotherapy for acute lymphoblastic leukaemia who subsequently developed ITP secondary to SARS-CoV-2 infection. Our patient had prolonged thrombocytopenia secondary to ITP, requiring the use of second-line agents including romiplostim and eltrombopag. This is a unique case where ITP was recognised secondary to SARS-CoV-2. In such cases of thrombocytopenia, ITP should be considered as an important differential in addition to relapse of leukaemia or thrombocytopenia due to chemotherapy drugs.


Subject(s)
COVID-19 , Precursor Cell Lymphoblastic Leukemia-Lymphoma , Purpura, Thrombocytopenic, Idiopathic , Child , Child, Preschool , Female , Humans , Neoplasm Recurrence, Local , Precursor Cell Lymphoblastic Leukemia-Lymphoma/complications , Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy , Purpura, Thrombocytopenic, Idiopathic/complications , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombocytopenic, Idiopathic/drug therapy , SARS-CoV-2
5.
Am J Case Rep ; 22: e932557, 2021 Oct 21.
Article in English | MEDLINE | ID: covidwho-1478477

ABSTRACT

BACKGROUND COVID-19 is associated with many hematological manifestations, including lymphopenia and thrombosis. There have been rare occasions in which thrombocytopenia has been reported as the sole clinical presentation of COVID-19. CASE REPORT This is the case report of a 48-year-old Hispanic female patient with COVID-19 presenting as severe isolated thrombocytopenia. The patient presented to the Emergency Department with hemoptysis, spontaneous bruising, and excessive vaginal bleeding and also reported a recent flu-like illness. On examination, she was found to have bilateral subconjunctival hemorrhage, diffuse oral ulcers, epigastric abdominal tenderness, and ecchymosis on her chest, with scattered petechiae and palpable purpura on her lower limbs. Laboratory results were significant for a platelet count of 0×109 and an immature platelet fraction of 34.1%. Owing to clinical suspicion, the patient was tested for COVID-19, and her test result was positive. She was treated with intravenous immunoglobulin, prednisone, rituximab, vitamin C, and zinc. Upon achieving hemodynamic stability, she was discharged to follow up with a hematologist in the outpatient setting. CONCLUSIONS Hematological consequences of COVID-19 are becoming more prevalent. The mechanism behind this manifestation could be bone marrow failure, formation of platelet autoantibodies, or consumptive coagulopathy. These critical manifestations are necessary to manage, especially in severe forms like in our patient. Steroids and rituximab combination therapy have proven to be the most effective regimen.


Subject(s)
COVID-19 , Purpura, Thrombocytopenic, Idiopathic , Thrombocytopenia , Female , Humans , Middle Aged , Purpura, Thrombocytopenic, Idiopathic/complications , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombocytopenic, Idiopathic/drug therapy , Rituximab , SARS-CoV-2
7.
Am J Case Rep ; 22: e931517, 2021 Sep 02.
Article in English | MEDLINE | ID: covidwho-1413537

ABSTRACT

BACKGROUND Immune thrombocytopenia (ITP) is rare in infants under 1 year old. Bleeding often occurs when the platelet count is <20 000/uL. The disease can progress because of accompanying COVID-19 disease. CASE REPORT A 9-month-old boy, weighing 8.5 kg, came to the hospital with petechiae on the forehead, cheeks, mouth, and extremities. The patient had rhinorrhea for 3 days previously and was febrile, pale, weak, and could not drink. He had the measles-rubella vaccination 19 days prior. Physical examination showed no abnormalities of the eyes, ears, nose, throat, and mouth. Heart and lungs were within normal limits, with no organomegaly, lymphadenopathy, or congenital anomaly of the abdomen. Laboratory examination showed hemoglobin, 12.7 g/dL; leukocytes, 7420/uL; platelet count, 16 000/uL; and hematocrit, 37.9%. Erythrocyte sedimentation rate was 14 mm at 1 h and 21 mm at 2 h. Peripheral blood smear showed normal RBC morphology, normal leukocytes, and few platelets. IgG was reactive and IgM was nonreactive on rapid antibody test. RT-PCR was positive for SARS-COV-2. Chest-X-ray showed pneumonia. The diagnosis was newly diagnosed ITP with COVID-19. Patient was treated with 30 mg/kg body weight/day of IV methylprednisolone for 3 days (250 mg); then 20 mg/kg body weight/day (175 mg) orally for 4 days in 3 divided doses. Azithromycin 100 mg/day, zinc 20 mg/day, and vitamin C 50 mg/day orally were also given. CONCLUSIONS COVID-19 screening is highly recommended during this pandemic to identify it as a potential cause of childhood ITP. Megadose methylprednisolone had an excellent response in alleviating ITP with confirmed COVID-19 in an infant.


Subject(s)
COVID-19 , Purpura, Thrombocytopenic, Idiopathic , Humans , Infant , Male , Methylprednisolone/therapeutic use , Pandemics , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombocytopenic, Idiopathic/drug therapy , SARS-CoV-2
9.
J Stroke Cerebrovasc Dis ; 30(11): 106072, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1377775

ABSTRACT

Recently cases of vaccine-induced immune thrombotic thrombocytopenia (VITT) and thrombosis following the adenoviral vector vaccine against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were reported. A mechanism similar to heparin-induced thrombocytopenia was proposed with antibodies to platelet factor 4 (PF4). Vaccine related arterial thrombosis in the brain is rare but life-threatening and optimal treatment is not established. We report clinical, laboratory, imaging findings and treatment in a 51-year-old female presenting with acute left middle cerebral artery (MCA) occlusion 7 days after the first dose of ChAdOx1 nCoV-19 vaccine. Due to low platelet count and suspicion of VITT she was not eligible for intravenous thrombolysis (IVT) and proceeded to mechanical thrombectomy (MER) with successful recanalization four hours after onset of symptoms. Treatment with intravenous immunoglobulin (IVIG) and heparin pentasaccharide fondaparinux was initiated. Presence of anti-PF4 antibodies was confirmed. The patient improved clinically with normalization of platelet count. Clinicians should be alert of VITT in patients with acute ischemic stroke after ChAdOx1 nCov-19 vaccination and low platelet counts. MER showed to be feasible and effective. We propose considering MER in patients with VITT and large vessel occlusion despite thrombocytopenia. High-dose IVIG should be started immediately. Alternative anticoagulation to heparin should be started 24 hours after stroke onset unless significant hemorrhagic transformation occurred. Platelet transfusion is contraindicated and should be considered only in severe hemorrhagic complications. Restenosis or reocclusion of the revascularized artery is possible due to the hypercoagulable state in VITT and angiographic surveillance after the procedure is reasonable.


Subject(s)
COVID-19 Vaccines/adverse effects , COVID-19/prevention & control , Infarction, Middle Cerebral Artery/chemically induced , Ischemic Stroke/chemically induced , Purpura, Thrombocytopenic, Idiopathic/chemically induced , Anticoagulants/therapeutic use , COVID-19/immunology , COVID-19/virology , Female , Humans , Immunoglobulins, Intravenous/therapeutic use , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/immunology , Infarction, Middle Cerebral Artery/therapy , Ischemic Stroke/diagnostic imaging , Ischemic Stroke/immunology , Ischemic Stroke/therapy , Middle Aged , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombocytopenic, Idiopathic/immunology , Purpura, Thrombocytopenic, Idiopathic/therapy , Thrombectomy , Treatment Outcome
10.
J Obstet Gynaecol Res ; 47(11): 4077-4080, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1367347

ABSTRACT

Over 26 million cases of coronavirus disease 2019 (COVID-19) have been reported in the United States with over 440 000 deaths. Despite COVID-19 vaccine approval, pregnant women were excluded from clinical trials. We report a case of immune thrombocytopenia in the first trimester, which occurred 13 days after initiating the COVID-19 vaccination series. Thorough evaluation, including hematology consultation, established the diagnosis. High-dose oral corticosteroids were started, and she was discharged home with significant improvement in platelet count on her fourth day of hospitalization with no subsequent complications. We advocate that the benefits of COVID-19 vaccination outweigh the risk of infection in pregnancy and that pregnant women should be included in clinical trials. Closer post-vaccination surveillance may be warranted in the pregnant population pending further data.


Subject(s)
COVID-19 , Purpura, Thrombocytopenic, Idiopathic , COVID-19 Vaccines , Female , Humans , Pregnancy , Purpura, Thrombocytopenic, Idiopathic/chemically induced , Purpura, Thrombocytopenic, Idiopathic/diagnosis , SARS-CoV-2 , United States , Vaccination
11.
BMC Pregnancy Childbirth ; 21(1): 567, 2021 Aug 18.
Article in English | MEDLINE | ID: covidwho-1365335

ABSTRACT

BACKGROUND: Coronavirus disease 2019 (COVID-19) still is a global emergency. According to the studies, pregnant women are of the at risk populations and any underlying disease(s) might even worsen their condition. The aim of this study is reporting a complex case of immune thrombocytopenic purpura (ITP) during pregnancy who has been diagnosed with COVID-19 as well as suspicion of HELLP syndrome. CASE PRESENTATION: A 24-year-old woman with a platelet count of 6000/mL and resistance to conventional therapies was referred. A day after starting 0.5 g/day of methylprednisolone for her, fever and a decrease in SpO2 presented. According to the paraclinical investigations, COVID-19 was diagnosed and the conventional COVID-19 treatments started for her (the methylprednisolone pulse stopped). Due to the increased liver enzymes and low platelet count, with suspicion of HELLP syndrome, cesarean section surgery was performed which resulted in a healthy neonate. Then, the methylprednisolone pulse was restarted for and she developed an increase in the platelet count. CONCLUSION: It is not clear how COVID-19 and pregnancy affected the patient's condition and the underlying disease; however, it seems the delivery and/or restarting the methylprednisolone pulses caused improvement in her condition.


Subject(s)
COVID-19/diagnosis , Methylprednisolone/administration & dosage , Pregnancy Complications, Hematologic/drug therapy , Pregnancy Complications, Infectious/diagnosis , Purpura, Thrombocytopenic, Idiopathic/drug therapy , Antiviral Agents/therapeutic use , COVID-19/complications , COVID-19/drug therapy , COVID-19/virology , Cesarean Section , Drug Resistance , Female , HELLP Syndrome/diagnosis , Humans , Infant, Newborn , Male , Platelet Count , Pregnancy , Pregnancy Complications, Hematologic/blood , Pregnancy Complications, Hematologic/diagnosis , Pregnancy Complications, Infectious/drug therapy , Pregnancy Complications, Infectious/virology , Pulse Therapy, Drug , Purpura, Thrombocytopenic, Idiopathic/blood , Purpura, Thrombocytopenic, Idiopathic/complications , Purpura, Thrombocytopenic, Idiopathic/diagnosis , SARS-CoV-2/isolation & purification , Treatment Outcome , Young Adult
13.
BMJ Case Rep ; 14(7)2021 Jul 30.
Article in English | MEDLINE | ID: covidwho-1334542

ABSTRACT

A 26-year-old woman was sent to the emergency room by her primary care physician for a new petechial rash and thrombocytopenia 2 weeks after receiving the Moderna mRNA-1273 SARS-CoV-2 vaccine. Her hospital course was complicated by transaminitis. Her platelet count improved to normal on hospital day 5 after receiving intravenous steroids and intravenous immunoglobulin to treat her suspected diagnosis of immune thrombocytopenic purpura. Extensive workup for her thrombocytopenia and transaminitis was unremarkable including ruling out infectious, autoimmune and toxic causes. A liver biopsy was unrevealing and her transaminitis was improved on discharge. Although not proven, the temporal relationship of her vaccination with thrombocytopenia and abnormal liver enzymes points towards the Moderna mRNA-1273 SARS-CoV-2 vaccine as the most likely inciting factor.


Subject(s)
COVID-19 , Purpura, Thrombocytopenic, Idiopathic , Adult , COVID-19 Vaccines , Female , Humans , Liver , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombocytopenic, Idiopathic/drug therapy , SARS-CoV-2
14.
BMJ Case Rep ; 14(7)2021 Jul 20.
Article in English | MEDLINE | ID: covidwho-1319391

ABSTRACT

A 61-year-old woman who had tested positive for COVID-19 in the community 5 days prior to admission presented with new onset severe headache and mild shortness of breath. She had an acute reduction in her platelet counts from 153×109/L to 5×109/L. She was diagnosed with immune thrombocytopenia purpura and after treatment with intravenous immunoglobulin, her platelet count increased to 15×109/L. Due to nonresolving headache, she had a magnetic resonance venogram, which showed bilateral internal jugular vein thrombosis. She was discharged from hospital and followed up in Haematology and Neurology clinics. Her platelet count returned to normal range 7 days later. She was commenced on anticoagulation for thrombosis.


Subject(s)
COVID-19 , Purpura, Thrombocytopenic, Idiopathic , Thrombosis , Female , Humans , Jugular Veins/diagnostic imaging , Middle Aged , Purpura, Thrombocytopenic, Idiopathic/complications , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombocytopenic, Idiopathic/drug therapy , SARS-CoV-2
15.
J Thromb Haemost ; 19(9): 2263-2267, 2021 09.
Article in English | MEDLINE | ID: covidwho-1297836

ABSTRACT

BACKGROUND: Vaccine-induced immune thrombocytopenia and thrombosis (VITT) following the administration of the AstraZeneca (AZ) ChAdOx1 nCOV-19 vaccine has recently been reported. The associated clinical and laboratory features have included thrombosis at unusual sites, thrombocytopenia, and raised D-dimers with positivity for IgG anti-platelet factor 4 (PF4) antibodies. OBJECTIVES: A UK National External Quality Control Assessment Scheme external quality control exercise was carried out by distributing liquid and lyophilized samples from a subject with VITT, a pool of samples from subjects with classical heparin-induced thrombocytopenia (HIT), and a non-VITT/non-HIT case to 85 centers performing HIT testing. METHODS: Participating centers employed their locally validated testing methods for HIT assays. RESULTS: The lyophilized and liquid samples were found to be commutable for the ELISA assays used in the detection of anti-PF4 antibodies. The Aeskulisa, Stago, Hyphen, and LIFECODES anti-PF4 ELISA assays successfully detected the VITT antibody, whereas the Acustar HIT, Werfen LIA, and the Stago STIC assays did not. CONCLUSION: It is important that clinical and laboratory teams are aware of the limitations of some anti-PF4 assays when using them to aid diagnosis of VITT syndrome.


Subject(s)
Purpura, Thrombocytopenic, Idiopathic , Thrombocytopenia , Thrombosis , Vaccines , COVID-19 Vaccines , Heparin/adverse effects , Humans , Platelet Factor 4 , Purpura, Thrombocytopenic, Idiopathic/chemically induced , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Thrombocytopenia/chemically induced , Thrombocytopenia/diagnosis , United Kingdom
17.
Int J Lab Hematol ; 43(4): 559-570, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1273095

ABSTRACT

COVID-19 (coronavirus disease 2019) represents a pandemic, and several vaccines have been produced to prevent infection and/or severe sequelae associated with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection. There have been several reports of infrequent post vaccine associated thrombotic events, in particular for adenovirus-based vaccines. These have variously been termed VIPIT (vaccine-induced prothrombotic immune thrombocytopenia), VITT (vaccine-induced [immune] thrombotic thrombocytopenia), VATT (vaccine-associated [immune] thrombotic thrombocytopenia), and TTS (thrombosis with thrombocytopenia syndrome). In this report, the laboratory test processes, as utilised to assess suspected VITT, are reviewed. In published reports to date, there are notable similarities and divergences in testing approaches, potentially leading to identification of slightly disparate patient cohorts. The key to appropriate identification/exclusion of VITT, and potential differentiation from heparin-induced thrombocytopenia with thrombosis (HITT), is identification of potentially differential test patterns. In summary, testing typically comprises platelet counts, D-dimer, fibrinogen, and various immunological and functional assays for platelet factor 4 (PF4) antibodies. In suspected VITT, there is a generally highly elevated level of D-dimer, thrombocytopenia, and PF4 antibodies can be identified by ELISA-based assays, but not by other immunological assays typically positive in HITT. In addition, in some functional platelet activation assays, standard doses of heparin have been identified to inhibit activation in suspected VITT, but they tend to augment activation in HITT. Conversely, it is also important to not over-diagnose VITT, given that not all cases of thrombosis post vaccination will have an immune basis and not all PF4-ELISA positive patients will be VITT.


Subject(s)
COVID-19 Vaccines/adverse effects , COVID-19/prevention & control , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombocytopenic, Idiopathic/etiology , COVID-19 Vaccines/therapeutic use , Enzyme-Linked Immunosorbent Assay , Humans , Immunologic Tests , SARS-CoV-2/isolation & purification
19.
J Thromb Haemost ; 19(9): 2314-2317, 2021 09.
Article in English | MEDLINE | ID: covidwho-1262369

ABSTRACT

BACKGROUND: In December 2020 the Israeli Health Ministry began a mass vaccination campaign with the BNT162b2 vaccine. This was an important step in overcoming the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) pandemic. Autoimmune phenomenon have been described after receiving vaccinations. PATIENTS/METHODS: Here we describe a case series of patients who developed acquired Thrombotic Thrombocytopenic Purpura, a rare autoimmune disease, within several days of receiving the BNT162b2 vaccine. CONCLUSIONS: A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity should be evaluated in patients with history of aTTP before and after any vaccination, especially the SARS-CoV-2 vaccination, and immunosuppression treatment should be considered before vaccination in cases of low ADAMTS13 activity. Patients should be closely monitored after the vaccine for clinical situation and laboratory data. Post vaccination thrombocytopenia assessment should include immune thrombocytopenic purpura, vaccine-induced immune thrombotic thrombocytopenia and acquired thrombotic thrombocytopenic purpura.


Subject(s)
COVID-19 , Purpura, Thrombocytopenic, Idiopathic , Purpura, Thrombotic Thrombocytopenic , ADAMTS13 Protein , COVID-19 Vaccines , Humans , Purpura, Thrombocytopenic, Idiopathic/chemically induced , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombotic Thrombocytopenic/chemically induced , Purpura, Thrombotic Thrombocytopenic/diagnosis , Rare Diseases , SARS-CoV-2
20.
Lupus ; 30(9): 1515-1521, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1247525

ABSTRACT

Immune thrombocytopenia, also known as immune thrombocytopenic purpura (ITP), has been reported as an important complication related to COVID-19.We present a 49-year-old male patient with systemic lupus erythematosus with lupus nephritis, antiphospholipid syndrome and history of ITP who developed an ITP flare in the context of COVID-19. He had no bleeding manifestations and had a good response to prednisone treatment.We review the characteristics of the cases reported to date in the literature, with an analysis of 57 patients. Mean age was 56 years (±19.6 SD), and 50.9% were male. This was the first episode of ITP in most of the patients (86.05%), with SARS-CoV-2 acting as the initial trigger. We found that ITP flares may appear in both mild and severe COVID-19 cases. They also appeared at any time during the course of the disease, 48.2% of patients developed it during hospitalization, while it was diagnosed at admission in the rest of the cases. Platelet counts were significantly lower than other ITP series, with a median nadir platelet count of 8 × 109/L (IQR 2-17.75 × 109/L). These patients show a higher bleeding rate (61.4%) compared with other ITP series. They also show a better response to treatment, with good response to the first line therapies in 76.9% of them. The most common first-line treatment was intravenous immunoglobulin (IVIG), used alone or combined with corticosteroids in 40.4% and 32.7% of cases respectively, while 25% of patients received only corticosteroids.Our review suggests that COVID-19-related ITP can be seen even in previously healthy patients. Clinicians must be aware that ITP may appear both in mild and severe COVID-19, at any time during its course. Given that this kind of ITP seems to be associated with a higher bleeding risk, its diagnosis in a clinical scenario such as COVID-19, where anticoagulant therapy is frequently used, may be critical. Treatment with IVIG and/or corticoids is often effective.


Subject(s)
COVID-19/complications , Prednisone/administration & dosage , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Glucocorticoids/administration & dosage , Humans , Immunoglobulins, Intravenous/administration & dosage , Lupus Erythematosus, Systemic/complications , Male , Middle Aged , Platelet Count , Purpura, Thrombocytopenic, Idiopathic/drug therapy , Purpura, Thrombocytopenic, Idiopathic/virology , Treatment Outcome
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