Outcomes and management of immune thrombocytopenia secondary to COVID‐19: Cleveland clinic experience

Abstract

Background: Immune thrombocytopenia (ITP) is an acquired disease characterized by thrombocytopenia secondary to autoantibodies against platelets. Here, we report the clinical characteristics of coronavirus disease 2019 (COVID-19)-induced ITP cases.Study Design and Methods: We retrospectively reviewed 3255 COVID-19 patients. COVID-19-induced ITP was diagnosed after excluding possible common causes. Bleeding severity was assessed based on the modified World Health Organization (WHO) bleeding severity score. Results: We identified 11 (0.34%) patients with COVID-19-induced ITP. Of all patients, 63.6% were males and the median age was 63 years. The median time from COVID-19 diagnosis to the onset of ITP was 10 days.Bleeding observed in 63.6% of the patients. Clinically significant bleeding (WHO Grade 3) occurred in single patient who required blood transfusion. Standard treatment with glucocorticoids and intravenous immunoglobulin (IVIG) was effective in achieving excellent response in most cases. Of all patients, complete response and response to treatment were achieved in 45.5% and 27.3% patients, respectively. The median time to ITP recovery was 4 days. Eltrombopag was used in three patients who relapsed. Four patients required mechanical ventilation, and none of them survived secondary to hypoxic respiratory failure. Conclusion: ITP secondary to COVID-19 usually presents after the first week of symptoms beginning. Most of our patients had WHO Grade 1-2 bleeding scores. Standard treatment with glucocorticoids and IVIG is effective in achieving an excellent response. The safety of eltrombopag is not very well established in COVID-19 patients, and additional studies are needed for a better safety profile.

First-dose ChAdOx1 and BNT162b2 COVID-19 vaccines and thrombocytopenic, thromboembolic and hemorrhagic events in Scotland

“…Venous thromboembolic events are common in patients with COVID-19. Approximately 10% of patients with COVID-19 in hospitals (non-intensive care unit (ICU)) are diagnosed with venous thromboembolism and 28% of those in ICU 11,32,33,34 . The vaccine-induced adverse events after administration of the adenovirus-based SARS-CoV-2 vaccines (including the ChAdOx1 vaccine) have been described as vaccine-induced immune thrombotic thrombocytopenia (VITT) syndrome or thrombosis with thrombocytopenia syndrome resulting in a venous or arterial thrombosis, including CVST and thrombocytopenia 35 .…”

Secondary Immune Thrombocytopenia Associated With Asymptomatic COVID-19 Successfully Managed With Intravenous Immunoglobulin and Glucocorticoids

“…A recent systematic review involving 45 cases of new-onset ITP in COVID-19 patients reported that 22% of cases were treated with glucocorticoid alone, 29% were treated with IVIG alone, and 24.5% of cases were treated with a combination of glucocorticoid and IVIG [ 7 ]. A recent case series of 11 patients showed that three patients were managed with glucocorticoid alone, one patient was managed with IVIG alone, five patients were managed with a combination of glucocorticoid and IVIG, and two patients were managed with glucocorticoid and eltrombopag [ 8 ]. In summary, literature supports the use of combination IVIG and glucocorticoid as an early treatment modality in patients with active bleeding and severe thrombocytopenia.…”

SARS-CoV-2 and Autoimmune Cytopenia

“…Immune thrombocytopenic purpura (ITP) has been described in numerous case reports and case series in association with SARS-CoV-2. The incidence of ITP in SARS-CoV-2 has been described in one study as 0.34% [64].…”

“…The majority of new cases of ITP in SARS-CoV-2 patients have been reported in patients 50-70 years old [10,19,[64][65][66][67][68], although cases in children as young as 1 year and up to age 95 have been reported [64,69]. There have been two reported cases of pregnant women who developed de novo ITP associated with SARS-CoV-2 [64,70]. The increase in prevalence in older age is similar to ITP not associated with SARS-CoV-2 [71,72].…”

“…ITP associated with SARS-CoV-2 has been predominantly seen 7-14 days after the onset of symptoms, with many patients found to have thrombocytopenia on presentation to the hospital [10,19,64,68]. However, there have also been cases of delayed ITP occurring after one month of diagnosis [64], with 21% of cases in one series occurring after recovery from infection [19]. The variable time delay between COVID-19 symptoms and the occurrence of ITP in some cases may call into question the causal nature of SARS-CoV-2 with ITP.…”