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.