LAUSR

A 64-year-old man presented to our Emergency Department (ED) in April 2020, in the midst of the COVID-19 pandemic, complaining of 3 days of unexplained fever following a contact with a known SARS-CoV-2 positive subject, atraumatic epistaxis and appearance of muco-cutaneous petechiae. At first medical contact, the patient was afebrile, showed no difficulty breathing in room air with a peripheral oxygen saturation of 95%, and reported no symptoms attributable to SARS-CoV-2 infection. The past medical history included diabetes mellitus and arterial hypertension. The initial blood work-up showed isolated severe thrombocytopenia (2 × 109/L), a hemoglobin value of Hb 13.2 g/dL with MCV 87 fL, a white blood cell (WBC) count within normal limits, and a CRP of 11 mg/L (normal values < 10 mg/L). Dr. Clerici and Dr. Di Benedetto. The patient presented to the ED for fever and active bleeding; blood tests showed a newly discovered, unexplained thrombocytopenia. In this setting, the diagnostic approach to isolated thrombocytopenia is challenging and the emergent hematologic conditions, such as thrombotic microangiopathies (TMAs) and immune thrombocytopenia (ITP), must be carefully evaluated. In the patient described with severe thrombocytopenia and a probable infection, disseminated intravascular coagulation (DIC) is another potential cause of concern. During the COVID-19 outbreak in Northern Italy, the presence of fever following a contact with a SARS-CoV-2 positive subject was a finding of equal clinical importance: the patient needed to be tested for SARS-CoV-2 so as to be appropriately allocated in the hospital setting. Moreover, it must be noted that COVID-19 has been associated with the onset of DIC, but generally only in critically ill patients. Therefore, coagulation tests, including fibrinogen and D-dimer, hemolysis work up, and testing with the locally available rRT-PCR test for SARS-CoV-2 must be obtained in a timely manner. Prothrombin time, activated partial thromboplastin time, fibrinogen and D-dimer were within normal limits. Furthermore, there were no signs of hemolysis, the patient’s renal function was preserved and schistocytes were absent in the peripheral blood smear. The patient tested positive for SARS-CoV-2 at the first nasopharyngeal swab performed in the E.R. The chest X-ray showed a pattern of bilateral interstitial pneumonia, which was confirmed by chest computer tomography (CT) (Fig. 1), which also revealed the presence of two enlarged lymph nodes in the left axillary region. Dr. Bertinato and Dr. Caberlon. The diagnosis of SARSCoV-2 infection is confirmed. Although imaging findings of bilateral interstitial pneumonia are present, the patient is stable and does not require supplemental oxygen therapy. COVID-19 may be associated with thrombocytopenia, which, however, is generally mild [1]. TMAs have been ruled out. Similarly to other viral infections, SARSCoV-2 has been related to the onset of ITP, but only one case has been described [2]. Moreover, not all cases of ITP require specific treatment. In the presence of a platelet count < 30 × 109/L and of active bleeding, however, treatment initiation is required [3]. With consideration of thrombocytopenia severity and of the bleeding diathesis, a platelet pool transfusion can be considered as the patient’s initial treatment. Monitoring of the platelet count shortly after a platelet pool transfusion may be of help to detect the presence of peripheral platelet destruction, and thus justify the initiation of ITP treatment, although the diagnosis has not yet been made. First-line treatment options for ITP include corticosteroids and intravenous immunoglobulin (IvIg); of the two, corticosteroids induce a more persistent increase in platelet count, and appear more suitable in this case. * Gian Marco Podda [email protected]