key: cord-0714805-s7hurlux authors: Lowe, Patrick P.; Egan, Daniel J.; Wilcox, Susan R.; Wittels, Kathleen A. title: Case Presentations of the Harvard Affiliated Emergency Medicine Residencies: A Case of Bleeding During Infection with COVID-19 A Case of Bleeding During Infection with COVID-19 date: 2021-10-30 journal: J Emerg Med DOI: 10.1016/j.jemermed.2021.10.040 sha: 87a54fa830567861482e4d0705417859416f3535 doc_id: 714805 cord_uid: s7hurlux Dr. Patrick Lowe: Our case today is that of a 47-year-old woman who was referred to our emergency department (ED) due to bloody urine, dark tarry stools, red spots on her skin, and bruising throughout her body. Fourteen days prior to presentation, she began exhibiting intermittent fevers, headache, shortness of breath, and a dry cough, and she tested positive for SARS-CoV-2 (the virus that causes COVID-19 pneumonia). Over the 3 days prior to her ED presentation, she experienced a headache that was more intense than the headaches she had been having in the preceding 2 weeks. She reported episodes of both dark urine as well as bright red blood in her urine. In addition, she had multiple dark stools described as tar-like when asked. On the day of her ED presentation, the patient noted a red rash throughout her body. In addition, earlier in the day, she had atraumatic self-limited epistaxis. She denied any falls or head strikes, vision changes, focal weakness or numbness, shortness of breath, chest pain, abdominal pain, or peripheral swelling. asked. On the day of her ED presentation, the patient noted red rash throughout her body. Additionally, earlier in the day she had atraumatic self-limited epistaxis. She denied any 32 falls or head strikes, vision changes, focal weakness or numbness, shortness of breath, chest pain, 33 abdominal pain, or peripheral swelling. 34 Dr. Daniel Egan: Does the patient have any personal or family medical history or medications 35 that might be relevant to her presentation? 36 Dr. Lowe: The patient has anxiety and depression for which she takes escitalopram, propranolol 37 and trazadone. Additionally, she has a history of migraines for which she takes sumatriptan. She 38 had lung cancer treated with surgical resection two decades prior to presentation. In the setting of 39 recent COVID-19 infection and increased headaches, she was taking ibuprofen 800mg three 40 times most days for the last two weeks. She has no personal or family history of known 41 coagulopathies or hematologic disorders. Approximately 1 week prior to being diagnosed with 42 COVID-19, the patient received a SARS-Cov2 mRNA-based vaccination (BNT162b2; Pfizer-43 BioNTech) for the first time. 44 Dr. Kathleen Wittels: Can you describe the physical examination? 45 Dr. Lowe: On arrival, the patient was normotensive and afebrile with a pulse of 58 beats per 46 minute, a respiratory rate of 18 breaths per minute and oxygen saturation of 97% breathing room air. She was well-appearing. Cardiopulmonary exam was significant for a bradycardic rate and 48 regular rhythm without murmur, and breath sounds were clear to auscultation throughout all lung 49 fields. Her abdomen was soft and non-tender without organomegaly. Examination of the skin 50 revealed scattered petechiae throughout the trunk, back, and extremities. There were areas of oropharynx demonstrated petechiae on the hard palate. On neurological assessment, the patient 53 was alert and oriented with a normal cranial nerve assessment. A complete motor, sensory and 54 gait assessment were also normal. 55 Dr. Susan Wilcox: What was on your differential diagnosis? 56 The change in the patient's headache raised concern for thrombotic and hemorrhagic pathology 82 including cerebral venous sinus thrombosis and intracranial hemorrhage, especially 83 intraparenchymal hemorrhage in the setting of signs of bleeding and presumed coagulopathy. 84 Dr. Egan: Can you describe your initial management and work-up of this patient? 85 Dr. Lowe: On arrival, the patient was hemodynamically stable and displayed no signs of 86 ongoing bleeding that required emergent intervention prior to pursuing laboratory and imaging 87 evaluation. Laboratory studies were notable for normal white blood cell count, a normocytic 88 anemia with hemoglobin of 11.3 g/dL (reference range (RF) 11.6-16.5 g/dL) and mean corpuscle 89 volume 94.3 fL (RF 80-100 fL). The platelet count was 1,000/L (RF 150,000-450,000/L). 90 Reticulocytes were measured at 1% (RF 0.7-2.5%). Blood smear did not reveal schistocytes. The 91 prothrombin time (PT) was 12.2 seconds (RF 11.5-14.5 seconds), international normalized ratio 92 0.9 (RF 0.9-1.1) and the partial thromboplastin (PTT) was 29.7 seconds (RF 23.8-36.6 seconds). 93 The fibrinogen level was 430 mg/dL (RF 200-450 mg/dL), d-dimer was 1,366 ng/mL (RF <500 94 ng/mL), lactate dehydrogenase was 276 U/L (RF 135-225 U/L), folic acid >20 ng/mL (RF >4 bradycardia without evidence of heart block or ischemia and the high-sensitivity cardiac troponin 97 was not elevated. Urinalysis revealed 3+ blood. A computed tomography (CT) scan of the brain 98 was performed without evidence of bleeding and a CT venogram did not reveal any thrombosis. 99 The patient was consented to receive blood products and the blood type and screen was obtained. 100 Given the concern for ITP, hematology consultation was obtained. After discussion of the 101 case and their bedside evaluation of the patient, the decision was made to treat for presumed ITP 102 with dexamethasone 40mg as well as intravenous immunoglobulin (IVIG) 1g/kg. Two units of 103 platelets were transfused. 104 Dr. Lowe: ITP is an autoimmune disease caused by destruction of platelets leading to a platelet 106 count below 100,000/L. 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