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Immune thrombocytopenia due to COVID-19 during pregnancy.
American Journal of Hematology ( IF 12.8 ) Pub Date : 2020-05-23 , DOI: 10.1002/ajh.25877
M W Tang 1 , Erfan Nur 1 , B J Biemond 1
Affiliation  

In April 2020, during the 2019 novel coronavirus disease (COVID‐19) pandemic caused by the virus SARS‐CoV‐2, a pregnant patient was diagnosed with immune thrombocytopenia (ITP) triggered by COVID‐19.

The 41‐weeks‐pregnant woman, with no significant past medical history, presented to the obstetric physician due to contractions. She had a sore throat but no other flu‐like symptoms. She had no signs of easy bruising or bleeding. Her vitals at presentation were a temperature of 36·4°C, respiration rate of 16/min, peripheral oxygen saturation (SpO2) of 98%, blood pressure of 115/80 mmHg, and pulse of 93/min. General laboratory examinations were performed, which showed a platelet count of 16 × 10E09/L. Two weeks earlier, the platelet counts were 98 × 10E09/L. The patient was suspected to have immune thrombocytopenia (ITP). Additional test with direct monoclonal antibody immobilization of platelet antigens (MAIPA) showed platelet auto‐antibodies against glycoprotein V. Throat and nose swabs were positive for SARS‐CoV‐2.

The patient was diagnosed with a first presentation of ITP, most likely triggered by COVID‐19. Treatment with intravenous immunoglobulin (IVIG) for 2 days was initiated. In order to be able to safely perform epidural anesthesia for the labor, 2 units of donor thrombocytes were administered. Her platelet counts increased to 80 × 10E09/L. Epidural anesthesia was complicated by hypotension with a suboptimal cardiotocography. Therefore, an urgent caesarian section was performed and a healthy daughter was born. Few hours later, she became hypoxic with a peripheral oxygen saturation of 91% without dyspnea. A chest CT showed infiltrates in the left lower lobe with ground‐glass opacities, typical of COVID‐19 (Figure S1). Within 24 hours, the peripheral oxygen saturation increased to 100% while breathing room air. Four days later, she was discharged without flu‐like symptoms and with stable platelet counts of 82 × 10E09/L that normalized 3 weeks later (315 × 10E09/L). Her newborn daughter did not develop any symptoms of COVID‐19. The newbornʼs platelets were 158 × 10E9/L at birth, but decreased to 41 × 10E09/L 5 days after birth. However, her platelets increased spontaneously thereafter, reaching 198 × 10E09/L at 3 weeks.

About 80% of patients infected with SARS‐CoV‐2 are asymptomatic or have mild flu‐like symptoms.1 While mainly a respiratory disease, COVID‐19 can trigger widespread systemic pathology, ranging from thrombo‐embolism, cardiovascular injury, hyper‐inflammatory syndrome, immune‐mediated pathology, and multi‐organ failure.2, 3 Interestingly, COVID‐19 has some unique aspects interfering with the immune system which are rarely observed in other respiratory viral infections.4 Lymphopenia and, at the same time, a cytokine storm, which is reflected by elevated levels of acute phase reactants, show an affected innate and adaptive immune system and are thought to predict disease severity. Similar to other viral infections,5 SARS‐CoV‐2 can also trigger ITP and probably autoimmune hemolytic anemia.6 Our patient developed a COVID‐19 induced ITP that was confirmed by a positive MAIPA. This case‐report shows that COVID‐19 can induce ITP even in patients with mild symptoms. Recently, Zulfiqar et al. reported a case of suspected ITP in a patient admitted due to COVID‐19.7 The patient had normal platelet counts at admission, but dropped gradually to 1 × 10E09/L in 8 days. However, no auto‐antibodies against glycoproteins were found and no response to IVIG was observed in that patient.

As SARS‐CoV‐2 is now very widespread, we suggest testing for SARS‐CoV‐2 in patients suspected of a (relapsed) ITP, even in the absence of respiratory symptoms.



中文翻译:

怀孕期间因 COVID-19 引起的免疫性血小板减少症。

2020年4月,在由病毒SARS-CoV-2引起的2019年新型冠状病毒病(COVID-19)大流行期间,一名孕妇被诊断出患有由COVID-19引发的免疫性血小板减少症(ITP)。

这位 41 周的孕妇,既往无明显病史,因宫缩而就诊于产科医师。她有喉咙痛,但没有其他类似流感的症状。她没有容易瘀伤或出血的迹象。就诊时她的生命体征是体温 36·4°C,呼吸频率 16/min,外周血氧饱和度(SpO 2) 98%,血压 115/80 mmHg,脉搏 93/min。进行一般实验室检查,显示血小板计数为 16 × 10E09/L。两周前,血小板计数为 98 × 10E09/L。该患者被怀疑患有免疫性血小板减少症(ITP)。使用直接单克隆抗体固定血小板抗原 (MAIPA) 的额外测试显示,血小板自身抗体针对糖蛋白 V。咽拭子和鼻拭子对 SARS-CoV-2 呈阳性。

该患者被诊断为首次出现 ITP,很可能是由 COVID-19 引发的。开始用静脉内免疫球蛋白 (IVIG) 治疗 2 天。为了能够安全地对分娩进行硬膜外麻醉,给予了 2 个单位的供体血小板。她的血小板计数增加到 80 × 10E09/L。硬膜外麻醉因低血压而复杂,心脏造影不理想。因此,进行了紧急剖腹产,并生下了一个健康的女儿。几小时后,她变得缺氧,外周血氧饱和度为 91%,没有呼吸困难。胸部 CT 显示左下叶浸润有磨玻璃影,典型的 COVID-19(图 S1)。在 24 小时内,呼吸室内空气时外周血氧饱和度增加到 100%。四天后,她出院时没有流感样症状,血小板计数稳定为 82 × 10E09/L,3 周后恢复正常(315 × 10E09/L)。她刚出生的女儿没有出现任何 COVID-19 症状。新生儿血小板出生时为158×10E9/L,出生5天后降至41×10E09/L。然而,此后她的血小板自发增加,在 3 周时达到 198 × 10E09/L。

大约 80% 感染 SARS-CoV-2 的患者没有症状或有轻微的流感样症状。1虽然主要是呼吸系统疾病,但 COVID-19 可引发广泛的全身病理学,包括血栓栓塞、心血管损伤、高炎症综合征、免疫介导的病理学和多器官衰竭。2, 3有趣的是,COVID-19 有一些独特的方面会干扰免疫系统,这在其他呼吸道病毒感染中很少观察到。4淋巴细胞减少症和细胞因子风暴(表现为急性期反应物水平升高)表明先天性和适应性免疫系统受到影响,并被认为可以预测疾病的严重程度。与其他病毒感染类似,5SARS-CoV-2 也可引发 ITP,并可能引发自身免疫性溶血性贫血。6我们的患者出现了 COVID-19 诱导的 ITP,经 MAIPA 阳性证实。该病例报告表明,即使在症状轻微的患者中,COVID-19 也可诱发 ITP。最近,Zulfiqar 等人。报告了一例因 COVID-19 入院的患者疑似 ITP 的病例。7患者入院时血小板计数正常,但在 8 天内逐渐下降至 1×10E09/L。然而,没有发现针对糖蛋白的自身抗体,也没有观察到该患者对 IVIG 的反应。

由于 SARS-CoV-2 现在非常普遍,我们建议对疑似(复发)ITP 的患者进行 SARS-CoV-2 检测,即使没有呼吸道症状。

更新日期:2020-07-14
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