PMC8636310_01
Chest high-resolution computed tomography (HRCT) images of the upper and lower lobes. (A) On the day of admission, extensive ground-glass opacities and consolidation were seen predominantly in the left lung, and traction bronchiectasis and volume reduction were also present. (B) On the 26th hospital day, antiviral therapy and corticosteroid treatment including two rounds of steroid pulse therapy resulted in a marked reduction of ground-glass opacities and consolidation although reticular shadows indicative of fibrotic changes were still present. (C) On the 39th hospital day, ground-glass opacities and consolidation reappeared in the bilateral lungs superimposed on reticular shadows indicating residual fibrotic change after COVID-19 pneumonia along with hemoptysis, purpura, and thrombocytopenia. A diagnosis of diffuse alveolar hemorrhage was made by bronchoalveolar lavage after the patient was intubated. (D) On the 51st hospital day, HRCT findings improved markedly with the increase in corticosteroid dosage.
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Chest auscultation revealed fine crackles across the bilateral lung fields. Chest X-ray revealed diffuse bilateral consolidations, and high-resolution computed tomography (HRCT) revealed extensive ground-glass opacities, consolidation with traction bronchiectasis, and volume reduction predominantly in the left lung (Fig. 1A). HFNC continued for approximately two weeks after admission, during which two courses of high-dose intravenous pulse therapy were administered. HRCT on the 26th hospital day (HD) showed significant improvement in the ground-glass opacities and consolidation although reticular shadows indicative of fibrotic changes remained, and he was weaned from oxygen therapy on the 32nd HD (Fig. 1, Fig. 2). HD, his respiratory condition rapidly deteriorated with the occurrence of hemoptysis, and HRCT showed the new appearance of extensive ground-glass opacities superimposed on reticular shadows indicative of residual fibrotic changes such as those seen after COVID-19 pneumonia (Fig. 1C). HRCT findings were similar to those at the onset of his COVID pneumonia, but RT-PCR testing for SARS-CoV-2 was negative. The patient's HRCT findings had generally improved by the 52nd HD (Fig. 1D), and he was discharged on the 73rd HD after undergoing rehabilitation.
Timeline of platelet counts in the 72-year-old male patient with immune thrombocytopenia during treatment of COVID-19 pneumonia. BMA, bone marrow aspiration; HFNC, high-flow nasal cannula; mPDN, methylprednisolone; MV, mechanical ventilation; PDN, prednisolone.
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Treatment was begun with high-flow nasal cannula (HFNC) for his respiratory failure and favipiravir 3600 mg/day on the 1st day, followed by 1600 mg/day, piperacillin/tazobactam 13.5 g/day, azithromycin 500 mg/day, heparin calcium 10,000 U/day, and methylprednisolone pulse therapy (Fig. 2). On the 35th HD, epistaxis and purpura on his lower limbs suddenly appeared (Fig. 3A), and a complete blood count revealed isolated thrombocytopenia with a platelet count of 1.0 x 109/muL that further declined to 0.2 x 109/muL on the 38th HD (Fig. 2). Corticosteroids were tapered from 70 mg/day (1 mg/kg) of prednisolone to 10 mg/day every other week (Fig. 2).
(A) Purpuric lesions on the patient's lower extremity. (B) Bronchoalveolar lavage fluid from the left B3 bronchus had a sanguineous appearance. (C) Cytological examination of the bronchoalveolar lavage fluid revealed histiocytes and neutrophils against a background of bleeding components (Papanicolaou stain) and (D) hemosiderin contained in alveolar macrophages (iron stain).
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On the 35th HD, epistaxis and purpura on his lower limbs suddenly appeared (Fig. 3A), and a complete blood count revealed isolated thrombocytopenia with a platelet count of 1.0 x 109/muL that further declined to 0.2 x 109/muL on the 38th HD (Fig. 2). Bronchoalveolar lavage in the left B3c showed increasingly hemorrhagic returns with a 74% recovery rate (Fig. 3B). Cytological examination of the bronchoalveolar lavage fluid revealed a significant hemorrhagic component and hemosiderin-containing alveolar macrophages stained with iron (Fig. 3C and D).