Severe Immune Thrombocytopenia Complicated by Intracerebral Haemorrhage Associated with Coronavirus Infection: A Case Report and Literature Review

NOTE: This article has been edited (3/28/20). This article refers to coronavirus, but not the COVID-19 coronavirus disease that is currently impacting the World. The comments from PDSA Medical Advisors are accurate. In addition, some doctors are reporting that severely affected COVID-19 patients have developed thrombocytopenia. Those patients were not ITP patients. PDSA will continue to monitor the situation and provide updates.

Virus illustration and doctorITP can develop after exposure to various infectious agents, including some viruses. ITP in this setting is often self-limited. Here, we review the report of a single case of ITP associated with contracting coronavirus (Covid-HKU1 not Covid-19) in Doha, Qatar. This otherwise healthy 24-year-old male developed severe thrombocytopenia with presumed ITP. The patient denied a family history of thrombocytopenia and did not have any underlying medication condition. He also denied exposure to any medications.

Approximately five days following the development of a fever and runny nose, the patient developed diffuse (dense) petechia on his extremities and abdomen, and oral mucosal bleeding. After two days of prolonged oral bleeding the patient went to the hospital and was found to have a platelet count of 1,000, and treatment with platelet transfusions, IVIG, and a 4-day pulse treatment of dexamethasone was initiated. This led to a rapid rise in platelet count within two days. However, shortly after treatment was initiated, the patient developed headache and vomiting, and was found to have a large frontal intracerebral hemorrhage. Following early detection, treatment and rehabilitation supported the patient making a full recovery. At some point, the patient was tested and found positive for coronavirus. The authors attribute the development of ITP to coronavirus infection although there are no preceding platelet counts to suggest pre-existing thrombocytopenia exacerbated by infection.

This is a very unusual case. To date, an increase in the incidence of ITP has not been reported in patients with coronavirus, even in China (see comment below).

Comments from PDSA’s Medical Advisors:

Many viral and other kinds of infections can temporarily lower platelet counts. In one review, at least 49 viruses have been reported as “causing ITP”. It is therefore no surprise that some patients with coronavirus infection will develop thrombocytopenia.

How do infections lower platelets?

There are reasons, including:

  • Severe infections can reduce platelet production in the bone marrow.
  • Some infections increase removal of platelets from the circulation.
  • Very rarely antibodies generated in response to the viral infection cross-react with platelets and because what appears to be ITP (not just thrombocytopenia), which is generally transient.

As posted earlier, colleagues from China and emerging published information suggest that patients with ITP are not at particular risk of getting coronavirus unless you are in an “ask risk” population due to age or because your ITP is being treated with drugs that suppress the immune system. There is no need to test for coronavirus simply because you have ITP.

What if you have ITP and you become infected with a current coronavirus such as Covid-19? So far, there hasn’t been any reports of patients with pre-existing ITP developing serious bleeding events during a Covid-19 infection. We expect that, like with any infection, platelets might go down somewhat if an ITP patient does become covid-19 infected, but this does not appear to be very frequent and not very serious. The case above was not known to have ITP previously. Your platelet count may somewhat reduce but there is no need for routine monitoring above and beyond that practiced normally. It may be appropriate to get a platelet count if you experience more bleeding or bruising as you would anyway.

Patients with ITP, especially those on corticosteroids or other immune suppressants, should stay at home whenever possible, be proactive in maintaining social distancing, wash hands frequently and follow the advice given by informed health officials to all members of the public.

We will continue to monitor our experience and that of others and let you know if there is any new information which might be important to our patients with ITP.

Immune Thrombocytopenia in Very Elderly Patients: Particularities in Presentation and Management. Results from the Multicenter Prospective Carmen-France Registry

Elderly woman's handsThis study describes the presentation and management of primary ITP in patients over the age of 65 with a particular focus on those over the age of 80. At least two recent studies have reported results in over 400 ITP patients in this age group, but to date there has not been a focus on the very elderly population. France maintains a national registry, which may provide the most generalizable data. This study from the CARMEN-France ITP registry involves patients from the French mid-Pyrenees region in the southwest of France with a population of approximately 3 million people. Data was obtained between June 2013 and December 2018 from 184 patients over the age of 65 years at the time they received a diagnosis of primary ITP and were known to have a normal bone marrow biopsy. Participants were divided into two groups: Elderly Patients (EP) age 65 years – 79 and Very Elderly Patients (VEP) who were over 80 years of age.

184 of the 541 Carmen registry ITP patients (about 1/3 of the total adult ITP population) were 65 years of age or older. The average age in the EP group (about 2/3 of the total) was 71.8 years and 85.7 years in the VEP group. Males were slightly predominant (63.2% vs. 60.8%), but there were no significant differences in average platelet count at diagnosis between the two groups (22.0 versus 18.0 x 109/L). VEP patients had more co-morbidities and were taking multiple medications more often. The frequencies of any bleeding event (58.6% versus 54.6%) and mucosal bleeding (25.3% versus 26.8%) were similar. However, severe bleeding was more frequent in the VEP group (10.3% versus 4.1%). This may have been influenced in part by an increased use of anti-platelet agents and anticoagulants. Other factors also associated with severe bleeding in the VEP group were polypharmacy (multiple medications) and comorbidities (other medical conditions). There was greater use of immunoglobulins in the VEP group, but the use of second line ITP treatments was similar.

Recent studies indicate that the incidence of ITP increases with age. For example, in this study about 1/3 of all adult patients with ITP in this region were above the age of 65. Therefore, special diagnostic and therapeutic decisions in the elderly population are of increasing significance to providers as well as patients. This study helps to focus our attention of the risks of age, co-morbidities and concurrent therapies on the risks and management of our more elderly patients. Learning more about the special vulnerabilities incurred by elderly patients is an important area for future research in ITP.


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