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Symptoms to Diagnosis

Severe thrombocytopenia in a patient with otherwise asymptomatic COVID-19

Lauren M. Granat, DO, MS, Achintya D. Singh, MBBS, MD, Matthew Cortese, MD, MPH, Vicente Velez, MD, FACP, FHM and Alan Lichtin, MD
Cleveland Clinic Journal of Medicine February 2021, 88 (2) 86-92; DOI: https://doi.org/10.3949/ccjm.88a.20154
Lauren M. Granat
Department of Internal Medicine, Cleveland Clinic
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  • For correspondence: [email protected]
Achintya D. Singh
Department of Internal Medicine, Cleveland Clinic
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Matthew Cortese
Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic
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Vicente Velez
Department of Hospital Medicine, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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Alan Lichtin
Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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    On the patient’s peripheral blood smear, no platelets were visible.

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    TABLE 1

    The patient’s complete blood cell count

    TestPatient’s valueaReference range
    White blood cell count7.03 × 109/L3.7–11.0
    Red blood cell count4.46 × 1012/L3.90–5.20
    Hemoglobin14.4 g/dL11.5–15.5
    Hematocrit41.2%36%–46%
    Platelet count3.0 × 109/L150–400
    Mean corpuscular volume92.4 fL80–100
    Mean corpuscular hemoglobin32.3 pG26.0–34.0
    Mean corpuscular hemoglobin35.0 g/dL30.5–36.0
    concentration
    Mean platelet volume11.7 fL9.0–12.7
    Red cell distribution width11.9%11.5%–15.0%
    coefficient of variance
    Reticulocytes84 × 109/L18–100
    1.9%0.4%–2.0%
    Neutrophils4.59 × 109/L1.45–7.50
    65.3%55%–70%
    Lymphocytes1.77 × 109/L1.00–4.00
    25.2%20%–40%
    Monocytes0.57 × 109/L< 0.87
    8.1%2%–8%
    Eosinophils0.09 × 109/L< 0.46
    1.3%1%–4%
    Basophils< 0.03 × 109/L< 0.11
    0.1%0.5%–1%
    Nucleated red blood cells< 0.01 × 109/L< 0.01
    0%0%
    • ↵a Abnormal results are shown in bold.

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    TABLE 2

    Differential diagnosis for thrombocytopenia

    DiseaseThrombocytopeniaHemolysisaADAMTS13PT/PTTFibrinogenD-dimer
    Thrombotic thrombocytopenic purpuraYesYesLowNormalNormalNormal
    Hemolytic uremic syndromeYesYesNormalNormalNormalNormal
    Disseminated intravascular coagulationYesYesNormalProlongedLowHigh
    Immune thrombocytopenic purpuraYesNoNormalNormalNormalNormal
    • ↵a Anemia, increased lactate dehydrogenase, decreased haptoglobin, increased reticulocyte count, increased unconjugated bilirubin.

    • ADAMTS13 = a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13; PT/PTT = prothrombin time and partial thromboplastin time

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    TABLE 3

    The patient’s chemistry panel

    TestPatient’s valueaReference range
    Sodium141 mmol/L136–144
    Potassium3.5 mmol/L3.7–5.1
    Chloride105 mmol/L97–105
    Carbon dioxide25 mmol/L22–30
    Blood urea nitrogen8 mg/dL7–21
    Creatinine0.97 mg/dL0.58–0.96
    Glucose69 mg/dL74–99
    Total protein6.9 g/dL6.3–8.0
    Calcium9.4 mg/dL8.5–10.2
    Total bilirubin4.1 g/dL3.9–4.9
    Conjugated bilirubin0.3 mg/dL0.2–1.3
    Alkaline phosphatase56 U/L34–123
    Alanine aminotransferase22 U/L7–38
    Aspartate aminotransferase19 U/L13–35
    Anion gap11 mmol/L9–18
    • ↵a Abnormal results are shown in bold.

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    TABLE 4

    The patient’s other blood tests

    TestPatient’s valueaReference range
    Immunoglobulin G1,120 g/L717–1,411
    Immunoglobulin A279 g/L78–391
    Immunoglobulin M123 g/L53–334
    Ferritin159 ng/mL14.7–205.1
    Interleukin 6< 2.2 pg/mL< 6.0
    C-creative protein0.1 mg/L< 0.9
    Creatine kinase122 U/L42–196
    Troponin T< 0.010 ng/mL0.000–0.029
    D-dimer790 μg/mL< 500
    Fibrinogen440 mg/dL200–400
    International normalized ratio1.30.9–1.3
    Prothrombin time10.3 s9.7–13.0
    Partial thromboplastin time25.4 s23.0–32.4
    Haptoglobin180 mg/dL81–238
    Lactate dehydrogenase304 U/L135–214
    CoombsNegativeNegative
    Hepatitis B surface antigenNegativeNegative
    Hepatitis B surface antibodyPositiveNegative
    Hepatitis B core antibody, totalNegativeNegative
    Hepatitis C antibody 1ANegativeNegative
    HIV1/2 antibodiesNegativeNegative
    SyphilisNonreactiveNonreactive
    • ↵a Abnormal results are shown in bold.

    • View popup
    TABLE 5

    Reported cases of COVID-19-associated immune thrombocytopenic purpura

    CasePresenting symptomsCOVID symptoms present before or on admission?Hospital day of decrease in platelet countInitial platelet count (× 109/L)First ITP interventionPlatelet count after first ITP intervention (× 109/L)Second ITP intervention (if applicable)Platelet count after second ITP intervention (×109/L)
    Hindilerdin et al22Easy bruising, fatigue, fever, dry coughYesDay 010IVIG 1 g/kg × 2 days25Prednisolone 1 mg/kg/day × 10 days100
    Tsao et al23Rash, purple lesions in mouth, bruisingYesDay 05IVIG 1 g/kg once320N/AN/A
    Artru et al24Dyspnea, fever, cough, astheniaYesDay 41IVIG 0.4 g/kg × 5 days Dexamethasone 40 mg/day × 4 days30Dexamethasone 40 mg/day × 4 days75
    Bennett et al25Fever, dyspnea, diarrhea, coughYesDay 0< 3IVIG 1g/kg × 2 days105N/AN/A
    Levesque et al26Dyspnea, dry cough, feverYesDay 2023IVIG 1 g/kg × 2 days Dexamethasone 40 mg × 4 days< 10Romiplostim daily × 10 days Vincristine × 1 day Methylprednisolone 500 mg IV × 4 days178
    Murt et al27Petechiae, easy bruisingYesDay 09IVIG 2 g/kg × 2 days54N/AN/A
    Bomhof et al28
    Patient 1Oral mucosal petechiae, spontaneous skin hematomasYesDay 0< 3Platelet transfusion IVIG 1 g/kg × 2 days47Dexamethasone51
    Patient 2Petechiae, bleeding from hemorrhoids, epistaxisYesDay 02Platelet transfusion Dexamethasone 40 mg daily × 4 days2IVIG32
    Patient 3Fever, coughing, dyspneaYesDay 123N/AN/AN/AN/A
    Granat et al (current case)NoneN/A03Platelet transfusion Dexamethasone 40 mg × 1 day67Prednisone 1 mg/kg × 4 days268
    • ITP = immune thrombocytopenic purpura; IVIG = intravenous immunoglobulin; N/A = not available

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Cleveland Clinic Journal of Medicine: 88 (2)
Cleveland Clinic Journal of Medicine
Vol. 88, Issue 2
1 Feb 2021
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Severe thrombocytopenia in a patient with otherwise asymptomatic COVID-19
Lauren M. Granat, Achintya D. Singh, Matthew Cortese, Vicente Velez, Alan Lichtin
Cleveland Clinic Journal of Medicine Feb 2021, 88 (2) 86-92; DOI: 10.3949/ccjm.88a.20154

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Severe thrombocytopenia in a patient with otherwise asymptomatic COVID-19
Lauren M. Granat, Achintya D. Singh, Matthew Cortese, Vicente Velez, Alan Lichtin
Cleveland Clinic Journal of Medicine Feb 2021, 88 (2) 86-92; DOI: 10.3949/ccjm.88a.20154
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  • Article
    • CAUSES OF THROMBOCYTOPENIA
    • BACK TO THE PATIENT
    • CAUSES OF SECONDARY IMMUNE THROMBOCYTOPENIC PURPURA
    • AN INTERESTING AND TIMELY PLOT TWIST
    • TREATMENT OF SEVERE SECONDARY IMMUNE THROMBOCYTOPENIA
    • BACK TO THE PATIENT
    • HEMATOLOGIC COMPLICATIONS OF COVID-19
    • DISCLOSURES
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