Shuqin Mei,1,* Cheng Xue,1,* Zheng Zhang,1 Lingling Liu,1 Wenwen Cai,2 Xuelian Gong,3 Zhiguo Mao,1 Xiaojing Tang,1 Bing Dai1 

1Kidney Institute of PLA, Department of Nephrology, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, People’s Republic of China; 2Department of Hematology, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, People’s Republic of China; 3Department of Nephrology, Qidong People’s Hospital, Affiliated Qidong Hospital of Nantong University, Nantong, Jiangsu, People’s Republic of China

*These authors contributed equally to this work

Correspondence: Xiaojing Tang; Bing Dai, Department of Nephrology, Kidney Institute of PLA, Shanghai Changzheng Hospital, Naval Medical University, Fengyang Road 415, Shanghai, 200003, People’s Republic of China, Email samitang@163.com; daibin105@163.com

Background: Severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection has been a global threat since the end of 2019. Although the main clinical manifestation of coronavirus disease 2019 (COVID-19) is respiratory, its range of clinical manifestation is extensive and may include various systems, including hematological disorders, such as lymphopenia, thrombotic events, thrombocytopenia and immune thrombocytopenic purpura (ITP). The present case was the first one that aimed to raise awareness of ITP induced by COVID-19 in patients undergoing maintenance hemodialysis.
Case Presentation: This is the case of a 75-year-old Asian woman who was diagnosed COVID-19 positive 15 days before attending our Emergency Department on January 19th, 2023, with a three-day history of severe bleeding symptoms, including gastrointestinal, mucosal bleeding, epistaxis, and the platelet count of 5× 109/L. She suffered from end-stage kidney disease due to autosomal dominant polycystic kidney disease and has received thrice-weekly maintenance hemodialysis (MHD) since 2012. Platelet count recovery was observed after 45 days of combined treatment with corticosteroids, intravenous immunoglobulin, thrombopoietin receptor agonists, and rituximab. The count of platelets rose to 180× 109/L after four dosages of Rituximab.
Conclusion: In brief, SARS-CoV-2 infection might trigger the onset of ITP. To our knowledge, this is the first case with severe and refractory ITP secondary to COVID-19 in MHD patients and no guidelines were able to be referred on the therapy. Nephrologists must be concerned with clinical characteristics, diagnostic flowcharts, and therapy for SARS-CoV-2-induced ITP.

Keywords: COVID-19, SARS-CoV-2, immune thrombocytopenic purpura, bleeding, platelet