Can COVID‐19 cause severe neutropenia?

Abstract

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) produces a broad spectrum of respiratory symptoms, from mild to pneumonia and acute respiratory distress syndrome. Coronavirus disease (COVID-19) is associated with an inflammatory syndrome that may increase damage to the lungs. Several hematopoietic and hemostatic abnormalities have been described, as well as autoimmune disorders. 1,2 2 | CASE HISTORY We report a 33-year-old woman, a surgical nurse, with no relevant medical history (although her sister was diagnosed with Hodgkin lymphoma), who was admitted to the Hematology Department at our hospital with severe neutropenia, asthenia, and enlarged lymph nodes 11 days after being diagnosed with COVID-19. On April 1, the patient presented at her family doctor (FD) with a sore throat, asthenia, and myalgia. SARS-CoV-2 polymerase chain reaction revealed positivity on oropharyngeal swabs obtained by the FD on April 2. She did not receive antiviral treatment, only acetaminophen when needed, and was discharged to her home to remain in isolation. Initially, her symptoms improved, but on April 13, she presented to the emergency department because of asthenia, gum swelling, and chills without fever or respiratory symptoms, such as shortness of breath or cough. Her vital signs, including oxygen saturation, were normal, and physical examination showed mild enlargement of the cervical, axillary, and inguinal lymph nodes without other pathological findings. 2.1 | Investigations and treatment Blood counts showed mild leukopenia (3.07 × 10 9 /L) with severe neutropenia (0.33 × 10 9 /L) and eosinopenia (0.05 × 10 9 /L) with a normal lymphocyte count, hemoglobin level, and platelet count. No morphological abnormalities were observed in the peripheral blood smear. Blood biochemistry assessment showed an increased level of C-reactive protein (2.51 mg/dL; normal, <0.5 mg/dL). Her lactate dehydrogenase level, liver function, and renal function were normal. Her interleukin-6 level was 20 pg/mL (normal, <7 pg/ mL). She had a fibrinogen level of 603 mg/dL with a normal D-dimer level. Her chest radiography was normal, and the pregnancy test result was negative. A new oropharyngeal swab for the SARS-CoV-2 test was performed on April 14, which continued to show positivity.

Febrile neutropenia due to COVID-19 in an immunocompetent patient

“…4 López-Pereira et al have reported one case of acquired severe neutropenia, in a 33-year-old woman with no relevant medical history. 5 The patient presented with severe neutropenia (0.33×10 9 /L), asthenia and mild generalised lymphadenopathy 11 days after the COVID-19 diagnosis. She had no fever associated with neutropenia, and her neutrophil counts recovered after a single dose of G-CSF.…”

“…The authors proposed transient agranulocytosis occurring early in COVID-19 infection or peripheral neutrophil consumption as potential mechanisms of transient neutropenia. 5 Spencer et al reported a 51-year-old man with NK-cell large granular lymphocytic leukaemia who had stable pancytopenia on cyclosporine therapy and presented with febrile illness and worsening of neutropenia from baseline when he was diagnosed with COVID-19 infection; he was successfully managed with antibiotics and G-CSF. 6 Our patient had normal baseline leucocyte and neutrophil counts when he was hospitalised for COVID-19 infection, and he subsequently developed delayed-onset, transient, severe neutropenia together with neutropenic fever, around the fifth week of illness.…”

A possible increased risk of metamizole‐associated neutropenia among COVID‐19 patients

“…Infection with SARS-CoV-2 cannot be ruled out with certainty as another possible cause for the observed neutropenia, since new onset neutropenia has been reported previously in patients with SARS-CoV-2 infection. 21,22 In 1 case, discontinuation of the drug led to an improvement in absolute neutrophils count; however, in the other 2, such an improvement was not observed and the patients died. Obviously, rechallenge was not done in any of the patients.…”

Delayed, transient and self-resolving neutropenia following COVID-19 pneumonia

“…Unlike our patient, they chose to give their patient G-CSF to improve the neutrophil count. 9 We chose to wait to administer G-CSF to see if the patient would produce the appropriate neutrophil response without intervention, which he successfully did. This was done due to the high risk of potentially causing severe complications, to include potential cytokine storm and death.…”