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Case Reports
. 2020 Dec 17;13(12):e238026.
doi: 10.1136/bcr-2020-238026.

COVID-19 presenting as thrombotic thrombocytopenic purpura (TTP)

Essam Altowyan  1 , Omar Alnujeidi  2 , Atheer Alhujilan  2 , Mohammed Alkathlan  2
Affiliations
Case Reports

COVID-19 presenting as thrombotic thrombocytopenic purpura (TTP)

Essam Altowyan et al. BMJ Case Rep. .

Abstract

We present the case of a 39-year-old man with epigastric pain, nausea and vomiting. The patient scored 4 in the Visual Triage Checklist of acute respiratory symptoms; a COVID-19 swab was taken. Prompt review of the peripheral blood smear showed evidence of microangiopathic haemolytic anaemia and thrombocytopenia. Because the patient had a picture of thrombotic thrombocytopenic purpura, plasma exchange and corticosteroids were started immediately. After 3 days, he developed severe ischaemic stroke and his swabs came back positive for COVID-19 by reverse transcription PCR. Therefore, triple therapy was started (lopinavir/ritonavir, ribavirin and interferon beta-1b). White blood cell count reached 50×109/L (normal range, 4.5-11×109/L), mainly neutrophils. All the workup for autoimmune diseases was negative. The patient showed delayed improvement in lactate dehydrogenase, haemoglobin and platelet count until we increased the volume of plasma exchange and subsided the inflammatory response of COVID-19. After that, the patient showed an excellent recovery.

Keywords: haematology (incl blood transfusion); influenza; malignant and benign haematology; stroke; thrombotic thrombocytopenic purpura.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Peripheral blood smear on admission showed 9% schistocytes.
Figure 3
Figure 3
CT of the brain: normal study and no evidence of bleeding or ischaemia.
Figure 2
Figure 2
Lactic acid dehydrogenase (LDH) chart from day 1 to day 17.
Figure 4
Figure 4
Platelet chart from day 1 to day 17.
Figure 5
Figure 5
White blood cell (WBC) chart from day 1 to day 17.
Figure 6
Figure 6
CT of the chest showed normal lungs and no pulmonary embolism.
Figure 7
Figure 7
Chest X-ray was normal.
See this image and copyright information in PMC

References

    1. Fifi JT, Mocco J. COVID-19 related stroke in young individuals. Lancet Neurol 2020;19:713–5. 10.1016/S1474-4422(20)30272-6 - DOI - PMC - PubMed
    1. Cataland S, Coppo P, Scully M, et al. COVID-19 and thrombotic thrombocytopenic purpura: frequently asked questions. American Society of hematology. Available: https://www.hematology.org/covid-19/covid-19-and-ttp [Accessed 22 Sep 2020].
    1. Castro JTdeS, Rittner L, Appenzeller S, et al. Association of plasmic score with neurological symptoms in patients with thrombotic thrombocytopenic purpura (TTP). Blood 2019;134:4894. 10.1182/blood-2019-129144 - DOI

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