P3C315: Immune Thrombocytopenia (ITP) Associated with sars-cov-2 in a 4-year-old Male

Introduction: Immune thrombocytopenia (ITP) is an acquired bleeding disorder characterized by thrombocytopenia induced by viral, environmental, or immunological triggers. It is believed to be secondary to a loss of immunological tolerance to platelet membrane antigens leading to destruction of platelets. About two-third of the cases are preceded by a viral illness.

Case Description: A 4-year-old male presented to the emergency department following a minor head injury with no loss of consciousness, but he was disoriented. Four days prior to this injury, he had bruising to his extremities and face. He had a recent upper respiratory infection due to SARS CoV-2 demonstrated by a positive RT-PCR test. In the ED, he had a Glasgow Coma Score of 14, and ecchymoses to the upper and lower extremities. Laboratory testing showed severe thrombocytopenia of 2,000. Mildly elevated prothrombin time to 14 with INR 1.2. Other blood clotting tests were normal. He tested positive for SARS CoV-2 IgG, and negative for IgM. A head CT scan showed subarachnoid hemorrhages involving the basal cisterns and frontal lobes, as well as mild soft tissue swelling of the right parietal scalp (figure 1).
Patient was admitted to PICU with diagnosis of viral infection (SARS CoV-2) induced thrombocytopenia, complicated by subarachnoid hemorrhages. He did not respond to two platelet transfusions but showed improvement after intravenous immunoglobulin and a 5-day course of methylprednisolone.
Over the next 6 days his neurologic status, and platelet count improved. Patient was discharged home with outpatient follow up, and his head CT continued to showed resolution of the hemorrhage.

Discussion: SARS CoV-2 infection presents with a wide range of clinical manifestations. Although thrombocytopenia is frequently present in children with SARS CoV-2 induced Multisystem inflammatory syndrome (MIS-C), and SARS CoV-2 induced Pediatric Acute Respiratory Syndrome (PARDS), isolated ITP is a less frequent presentation. In this case, given the history of a positive COVID-19 test and negative results for other common viral etiologies, it is likely that the novel coronavirus was the culprit. Although intracranial hemorrhage (ICH) has a low incidence in children of about 0.6%, it is most frequently seen with new onset diagnosis as observed in our patient. The exact pathophysiology is not clear, but it is postulated that the factors in figure 2 are most likely to be contributory.

Conclusion: It is important to bear in mind that the novel coronavirus can present in a multitude of ways. It can present in the form of isolated ITP, not associated with MIS-C or PARDS.
In our patient platelet transfusion did not improve platelet count, suggesting antibody or immune complex related thrombocytopenia, requiring IVIG and steroids.