CASE PRESENTATION
A 2-year-old boy presented to the Emergency Department with a purpuric
rash. The rash appeared one week ago, starting from his lower limbs, and
gradually spreading to his back and upper limbs. The patient had a
history of gingivitis a month ago with no known history of SARS-CoV-2
exposure. He did not report having fever, cough, difficulty breathing,
abdominal pain, bruising or bleeding. His past medical history was
unremarkable, and his immunization status was up to date for age.
Furthermore, he had no family history of hematological or autoimmune
disorders.
A purpuric rash and petechiae on his lower extremities, back and upper
limbs were noted. Full blood count (FBC) showed normal level of
leukocytes (12,7 x 109/L [43,5% neutrophils, 49,1%
lymphocytes, 6% monocytes]), normal hemoglobin (13.0 g/dL) and
hematocrit (36,4%) and low platelet count (3 x
109/L). The coagulation screening panel (PT, aPTT,
INR) as well as biochemistry tests were both normal. Immunoglobulins
were within normal range for his age. A respiratory pathogen panel was
negative for EBV, CMV, HSV, enterovirus/adenovirus, parvo-B19, chlamydia
pneumoniae and mycoplasma pneumoniae. Reverse transcriptase-polymerase
chain reaction testing (RT-PCR) was negative for SARS-CoV-2, but IgG
antibodies against SARS-CoV-2 were detected in the patient’s blood{2.85
( positive>1.1)} by using ELISA as a method of choice,
which provides semiquantitave in vitro determination of human antibodies
of the immunoglobulin class IgG against SARS-CoV-2. The specificity of
the test is 99.3% and the sensitivity depends on the time that the test
was performed. The negative RT-PCR was expected due to the time between
the oropharyngeal symptoms and the ITP first manifestation. The patient
was also found negative for any underlying primary autoimmune disease.
Our patient received intravenous immunoglobulin-G (IVIG) (1 gr/kg) and
he remained clinically stable with no active bleeding and gradual
improvement of the rash. He was discharged home after three days with a
progressive rise in his platelet count (54 x 109 /L).
Two days post discharge FBC was repeated manifesting further increase of
the platelet count. However, on the weekly follow-up his platelet count
deteriorated again (10 x 109/L), which led to his
readmission in our hospital for a second dose of IVIG (1gr/kg). Further
diagnostic tests included chest x-ray, and an abdominal ultrasound (both
normal), while he tested negative for occult fetal blood. A repeat blood
test for SARS-COV-2-IgG abs was found once again positive [2.93
(positive>1.1)]. The patient remained clinically well,
and he was discharged home with a close follow-up on a weekly basis. A
slow but steady rise in the platelet count (104.000X10_9/L) was noted
one month post discharge.