Abstract Introduction Immune thrombocytopenia (ITP), is an acquired thrombocytopenia caused by autoantibodies against platelet antigens. It is one of the common causes of thrombocytopenia in otherwise asymptomatic adults.ITP has emerged as a rare hematologic manifestation of COVID-19, occurring due to immune dysregulation and autoantibody-mediated platelet destruction. We present a case that highlights unique clinical intersection of prothrombotic and hemorrhagic risk in a patient with COVID-19 infection, emphasizing diagnostic complexity and therapeutic precision in the ICU setting. Case A 49-year-old male with a past medical history of diabetes mellitus and hypertension presented with acute left-sided weakness. Stroke workup including CT head, CT perfusion, and CTA of the head and neck confirmed acute infarction in the right anterior cerebral artery (ACA) and a small infarct in the right posterior cerebral artery (PCA) territory. MRI of the brain confirmed the findings, ECHO with bubble study revealed no Patent Foramen Ovale. Dual antiplatelet therapy (aspirin and clopidogrel) was initiated. Meanwhile the patient developed fever, tachycardia and leukocytosis (WBC 21.2 ×109/L), meeting criteria for sepsis. Infectious disease was consulted, and broad-spectrum antibiotics (vancomycin, cefepime) were initiated. Blood cultures, CSF studies, meningitis/encephalitis panel, HIV, Lyme, and urine cultures were all negative. On 4th day of hospitalization patient was found obtunded and was intubated. He tested positive for COVID-19 and was started on remdesivir. By day 6, his mental status improved and he was liberated from the ventilator. On hospital day 7, his platelets acutely dropped to 42 ×109/L and then to 1 ×109/L the following day. CT head was negative for intracranial hemorrhage. Differential included heparin-induced thrombocytopenia (HIT) versus ITP. Given the rapid decline and negative HIT evaluation, ITP was suspected. Physical examination at the time showed petechiae on abdomen and chest. Hematology was involved and he was treated with intravenous dexamethasone and IVIG resulting in improvement of platelet count. As his condition stabilized, he was discharged to continue on prednisone 40 mg daily for two weeks, with plans for hematology follow-up for tapering. Discussion The pathogenesis of ITP is incompletely understood. COVID-19-associated ITP is uncommon, but its occurrence in a patient with recent ischemic stroke on DAPT is diagnostically challenging. Temporal relationship between viral infection and profound thrombocytopenia supports an immune-mediated mechanism.Early recognition and prompt initiation of IVIG and corticosteroids remain the mainstay of treatment. This case represents a rare and complex overlap of COVID-19, ischemic stroke and secondary ITP, illustrating the delicate interplay between thrombosis, bleeding, and inflammation. This abstract is funded by: None
Qaiser et al. (Fri,) studied this question.
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