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Ono R, Kitagawa I. SARS-CoV-2 infection-induced immune thrombocytopenia: a systematic review of current reports. Ann Hematol 2024:10.1007/s00277-024-05765-1. [PMID: 38652242 DOI: 10.1007/s00277-024-05765-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/17/2024] [Indexed: 04/25/2024]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a low platelet count with increased risk of bleeding, and viral infection may trigger ITP. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection-induced ITP has been increasingly reported. We systemically reviewed the previously reported cases of SARS-CoV-2 infection-induced ITP and identified a total of 105 patients from 68 studies. The median age was 61 years, and 14 patients (12%) were < 18 years old (pediatric cases). In adult cases, a total of 53% patients were classified as moderate to severe SARS-CoV-2 infection. The median platelet count at diagnosis and nadir were 6,000/µL and 4,000/µL, respectively. When comparing platelet levels between non-severe SARS-CoV-2 infection and moderate to severe SARS-CoV-2 infection, the median values of platelet levels at diagnosis were not significantly different between the groups (4,000/µL in non-severe SARS-CoV-2 infection and 9,000/µL in moderate to severe SARS-CoV-2 infection, p-value = 0.22). Median nadir platelet levels were also not significantly different between groups (4,000/µL in non-severe SARS-CoV-2 infection and 8,000/µL in moderate to severe SARS-CoV-2 infection, p-value = 0.27). More than half of the cases (53 patients) were treated with combination therapy including steroid, intravenous immunoglobulin, and eltrombopag. Major bleeding and intracranial hemorrhage occurred in ten (11%) and six (6.6%) cases, respectively. The overall mortality rate was 7%. In pediatric cases, none of the patients experienced major bleeding and lethal outcomes.
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Affiliation(s)
- Ryohei Ono
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan.
| | - Izumi Kitagawa
- Department of General Internal Medicine, Shonan Fujisawa Tokushukai Hospital, Japan, 1-5-1 Tsujido Kandai, Fujisawa, Kanagawa, 251-0041, Japan
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Demharter NS, Rao P, Scalzi LV, Ericson JE, Clarke S. Prolonged Thrombocytopenia in a Case of MIS-C in a Vaccinated Child. J Investig Med High Impact Case Rep 2023; 11:23247096221145104. [PMID: 36594290 PMCID: PMC9829881 DOI: 10.1177/23247096221145104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) has been extensively described in patients following severe acute respiratory syndrome coronavirus 2 infection. There are now questions about what MIS-C may look like in vaccinated children. Multisystem inflammatory syndrome in children has many clinical and laboratory features in common with other inflammatory disorders including Kawasaki disease and toxic shock syndrome. Rheumatologic conditions can present with similar musculoskeletal complaints and elevated inflammatory markers. Laboratory markers and clinical symptoms of MIS-C usually improve once therapy is begun. We describe a child with persistent thrombocytopenia as an example of variable presentation of MIS-C in vaccinated children. This case report discusses an atypical progression of MIS-C in a vaccinated child with a known prior positive COVID-19 polymerase chain reaction (PCR) test. She presented with nonspecific abdominal pain and fever and was found to have elevated inflammatory markers, lymphopenia, and thrombocytopenia. Intravenous immunoglobulin and steroid treatment failed to induce rapid recovery in her clinical condition or thrombocytopenia. Rheumatologic, hematologic, oncologic, and infectious causes were considered and worked up due to the uncertainty of her case and persistence of pancytopenia but ultimately were ruled out with extensive testing and monitoring. It was key to include a broad differential including viral-induced bone marrow suppression, idiopathic thrombocytopenic purpura, secondary hemophagocytic lymphohistiocytosis, systemic juvenile idiopathic arthritis, and malignancy. The spectrum of MIS-C and response to treatment continues to evolve, and prior vaccination in this child's case complicated the clinical picture further. Additional evaluation of MIS-C in vaccinated cases will permit characterization of the range of MIS-C presentation and response to standard therapy.
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Affiliation(s)
| | - Pooja Rao
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Lisabeth V Scalzi
- Division of Pediatric Rheumatology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Jessica E Ericson
- Division of Pediatric Infectious Disease, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Sheila Clarke
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
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Marinescu AR, Lazureanu VE, Musta VF, Nicolescu ND, Mocanu A, Cut TG, Muresan CO, Tudoran C, Licker M, Laza R. Severe Thrombocytopenic Purpura Associated with COVID-19 in a Pediatric Patient. Infect Drug Resist 2022; 15:3405-3415. [PMID: 35794926 PMCID: PMC9252296 DOI: 10.2147/idr.s363716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/21/2022] [Indexed: 01/19/2023] Open
Abstract
Purpose Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is known to cause a diverse spectrum of clinical manifestations ranging from mild, flu-like symptoms to severe progressive pneumonia, acute respiratory distress syndrome with or without other extrapulmonary impairment. Hematological changes such as lymphopenia, neutrophilia, and anemia as the disease progresses, are frequently found in COVID-19. Thrombocytopenia may be drug-induced or can occur secondary to sepsis, disseminated intravascular coagulation or bone marrow suppression. Immune thrombocytopenic purpura (ITP) is frequently observed in children aged 2-5 years and in 60% of cases may proceed an upper respiratory tract infection. The present paper aimed to raise awareness of ITP as a possible pediatric presentation of coronavirus disease. Patients and Methods We present the case of previously healthy, eight-year-old female patient, who developed an immune thrombocytopenia flare, also known as immune thrombocytopenic purpura (ITP), in the context of COVID-19, with diffuse petechiae and ecchymosis on her body, face and oral mucosa, and a nadir platelet count of 0×103/μL. Results Platelet count recovery was observed after seven days of combined treatment with intravenous immunoglobulin (IVIG) and corticosteroids. Conclusion The growing body of literature regarding the clinical and laboratory manifestations of COVID-19 infection in children, has reported thrombocytopenia in relation to unfavorable disease progression or multisystem inflammatory syndrome (MIS-C). Clinicians must be aware that ITP may appear both in mild and severe COVID-19, at any time during its course, and can be associated with a higher bleeding risk, thus its diagnostic may be critical.
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Affiliation(s)
- Adelina Raluca Marinescu
- Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania.,Victor Babes Clinical Hospital of Infectious Diseases and Pneumophtisiology, Timisoara, Romania.,Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Voichita Elena Lazureanu
- Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania.,Victor Babes Clinical Hospital of Infectious Diseases and Pneumophtisiology, Timisoara, Romania
| | - Virgil Filaret Musta
- Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania.,Victor Babes Clinical Hospital of Infectious Diseases and Pneumophtisiology, Timisoara, Romania
| | - Narcisa Daniela Nicolescu
- Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania.,Victor Babes Clinical Hospital of Infectious Diseases and Pneumophtisiology, Timisoara, Romania
| | - Alexandra Mocanu
- Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania.,Victor Babes Clinical Hospital of Infectious Diseases and Pneumophtisiology, Timisoara, Romania.,Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Talida Georgiana Cut
- Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania.,Victor Babes Clinical Hospital of Infectious Diseases and Pneumophtisiology, Timisoara, Romania.,Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania.,Center for Ethics in Human Genetic Identifications, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Camelia Oana Muresan
- Center for Ethics in Human Genetic Identifications, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania.,Discipline of Forensic Medicine, Bioethics, Deontology and Medical Law, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Cristina Tudoran
- Discipline of Internal Medicine II, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania.,Center of Molecular Research in Nephrology and Vascular Disease, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Monica Licker
- Discipline of Microbiology, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania.,Multidisciplinary Research Centre on Antimicrobial Resistance, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Ruxandra Laza
- Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania.,Victor Babes Clinical Hospital of Infectious Diseases and Pneumophtisiology, Timisoara, Romania
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Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with a variety of clinical manifestations related to viral tissue damage, as well as a virally induced immune response. Hyperstimulation of the immune system can serve as a trigger for autoimmunity. Several immune-mediated manifestations have been described in the course of SARS-CoV-2 infection. Immune thrombocytopenic purpura (ITP) and autoimmune hemolytic anemia (AIHA) are the most common hematologic autoimmune disorders seen in the course of SARS-CoV-2 infection. Vaccine-induced thrombocytopenia is a unique autoimmune hematologic cytopenia associated with SARS-CoV-2 vaccination. This paper will review the current literature on the association of SARS-CoV-2 infection and vaccination with autoimmune cytopenias and the clinical course of autoimmune cytopenias in patients with COVID-19.
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Cimolai N. Untangling the Intricacies of Infection, Thrombosis, Vaccination, and Antiphospholipid Antibodies for COVID-19. SN COMPREHENSIVE CLINICAL MEDICINE 2021; 3:2093-2108. [PMID: 34179695 PMCID: PMC8218573 DOI: 10.1007/s42399-021-00992-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 02/06/2023]
Abstract
Advanced SARS-CoV-2 infections not uncommonly associate with the occurrence of silent or manifest thrombotic events which may be found as focal or systemic disease. Given the potential complexity of COVID-19 illnesses, a multifactorial causation is likely, but several studies have focused on infection-induced coagulopathy. Procoagulant states are commonly found in association with the finding of antiphospholipid antibodies. The correlation of the latter with thrombosis and/or clinical severity remains controversial. Although measures of antiphospholipid antibodies most commonly include assessments for lupus anticoagulant, anticardiolipin, and anti-ß2-glycoprotein-I antibodies, lesser common antibodies have been detected, and there remains speculation that other yet undiscovered autoimmune thrombotic events may yet be found. The recent discovery of post-vaccination thromboses associated with platelet factor 4 antibody has created another level of concern. The pathogenesis of antiphospholipid antibodies and their role in COVID-19-related thrombosis deserves further attention. The multifactorial nature of thrombosis associated with both infection and vaccination should continue to be studied as new events unfold. Even if a cause-and-effect relationship is variable at best, such dedicated research is likely to generate other valuable insights that are applicable to medicine generally.
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Affiliation(s)
- Nevio Cimolai
- Faculty of Medicine, The University of British Columbia, Vancouver, BC Canada
- Children’s and Women’s Health Centre of British Columbia, 4480 Oak Street, Vancouver, BC V6H3V4 Canada
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