COVID-19-INDUCED EVANS SYNDROME: UNUSUAL COMPLICATION OF THE NEW USUAL

ABSTRACT

SESSION TITLE Management of COVID-19-Induced Complications SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/19/2022 1245 pm - 145 pm INTRODUCTION: Evans syndrome (ES) is a rare autoimmune disorder characterized by the combination of two or more cytopenias with an incidence of 0.8-3.7%.Here we present a case of COVID-19 pneumonia complicated by the development of ES. CASE PRESENTATION A 75-year-old female with the past medical history of 50 pack-year smoking, recent asymptomatic COVID-19 Pneumonia 2 week ago came to the emergency room (ER) with shortness of breath. Her vitals and physical exam were unremarkable. Labs were significant for leukocytosis of 11.66 and D-dimer of 3.32. CT pulmonary angiogram showed bilateral pulmonary embolism along with a COVID-19 pattern of pneumonia. She was started on heparin drip and was eventually discharged on Warfarin with Prednisone taper. After 3 weeks, she presented to the ER with worsening shortness of breath. She was found to have platelet count of 4k and Hb of 6.6 gm%(compared to 370k and 13.1 gm% on last discharge) and was started on transfusions which could not be completed due to development of mid-transfusion fever. She received Dexamethasone and IVIG. All forms of active bleeding were ruled out by bronchoscopy, CT scans and EGD. Flow cytometry was negative for ADAMTS13 ruling out thrombotic thrombocytopenic purpura. Bone marrow biopsy was unremarkable. She was positive for IgG warm agglutinin hemolytic anemia. She was discharged on long-term Prednisone taper. In the clinic she was given intermittent IVIG and Romiplostim to improve her counts. Due to multiple failed attempts to wean her off steroids, she was started on Rituximab with an excellent response of platelets increment to 450k and Hb to 8.5 gm%. Rituximab will be given for a total of 8 weeks. DISCUSSION: ES is considered to be caused by immune system dysregulation. ES in COVID-19 is a diagnostic dilemma as the thrombocytopenia is usually misdiagnosed as COVID-19 sequelae and leads to delay in diagnosis. The treatment of ES is usually with steroids 1 mg/kg/day but they only provide short term improvement. Rituximab, plasma exchange, IVIG, and splenectomy are second-line treatments for relapsing/refractory ES. Our patient had an acceptable response to steroids but it was transient,demonstrating the limited role of steroids in the long term and was eventually treated successfully with Rituximab. A review of limited published cases of ES caused by COVID-19 suggests that diagnosis, treatments, and prognosis are usually individualized according to patient characteristics, presenting symptoms, physician preference, and disease complications. CONCLUSIONS: ES is a very rare syndrome although it requires prompt treatment. It is important to be mindful about immunological causes when a COVID-19 patient presents with cytopenia, as delay in treatment can cause poor outcomes. Reference #1 Turgutkaya A, Bolaman AZ, Yavaşoğlu Í. COVID-19-associated Evans syndrome A case report and review of the literature. Transfus Apher Sci. 2021 Dec 7103339. doi 10.1016/j.transci.2021.103339. Epub ahead of print. PMID 34896007;PMCID PMC8655821. DISCLOSURES No relevant relationships by Nitesh Jain No relevant relationships by Kashyap Kela No relevant relationships by Princy Shah No relevant relationships by namita sharma No relevant relationships by AMIT SHARMA