ITP in a SARS-CoV-2 Positive Pediatric Patient: A Case Report

July 18, 2020

Faculty member Geoff Capraro interviews fellow, Hoi See Tsao.

Apologies to readers in advance, this blog does include the terms “coronavirus” and“SARS-CoV-2” and “COVID-19”. Do not be thwarted- this conversation with rising third year fellow Hoi See Tsao is nothing like what you’ll hear on the air waves, read in other news sources, or catch on social media. In fact, they all probably will come rushing to Brown PEM wondering how they can deliver such thoughtful and interesting corona talk. Be unafraid, and read on!

GC: So, congratulations on your recent case report accepted to Pediatrics, "Immune Thrombocytopenia in a SARS-CoV-2 Positive Pediatric Patient"! Whose idea was it to write-up the case?

HST:Thank you! Dr. Deirdre Fearon inspired me to write up the case during a shift that we had together. She showed me pictures of different pediatric dermatologic presentations of COVID-19 right before we met the patient in the case report. When we saw the patient's petechial rash and her workup showed that she had immune thrombocytopenia in the setting of testing positive for SARS-CoV-2, we were excited to write up this case to add to the medical community’s understanding of different manifestations of SARS-CoV-2 infection. We also wanted to highlight the importance of considering SARS-CoV-2 testing in patients with a new immune thrombocytopenia diagnosis to allow for appropriate hospital triaging and isolation, and to limit community spread and healthcare worker infection.

GC: What was it like working with attending Dr. Fearon and Emergency Medicine resident Hannah Chason?

HST: I loved it! I think that our different levels of training and backgrounds really helped the case report come together. Dr. Fearon, as our attending, provided oversight and guidance on which parts of the case would be interesting to the medical community and gave us direction for the case report writeup. As an Emergency Medicine resident and with her strong liberal arts college writing background, Dr. Chason's careful history-taking provided many of the crucial details of the patient presentation write-up, and was amazing at bringing the different components of the case together to improve the flow of the case report. We also had the privilege of consulting with Dr.Bradley DeNardo, a pediatric hematologist oncologist, who provided invaluable insight on the presentation, clinical course, workup and management of immune thrombocytopenia, and the differential to consider in patients with similar presentations and lab findings as the patient in our case report.


GC: Had you written a case report before?

HST:I have! Interestingly, perhaps due to the current push for COVID-19 publications to be published in an expedited fashion, this case report was published electronically before my other case report was (stay tuned!). I think that the experience of having written prior case reports was very helpful in the writeup of this case report, as there is a learning curve involved in terms of the knowledge and skill needed to present medical information succinctly in a written format while keeping the medical journal's target audience in mind.


GC: Why is the publication of case reports important?

HST:The publication of case reports is important because case reports are the initial stepping stones or observations that can lead to larger scale studies of associations or causation using rigorous research methods.


GC: What do you think are the most important knowledge gaps now regarding SARS-CoV-2?

HST: Due to technological advances and the widespread impact of COVID-19 globally, the speed at which our understanding of SARS-CoV-2 has grown has been unparalleled. However, there are still many knowledge gaps. In my opinion, the most important knowledge gap regarding SARS-CoV-2 is understanding its pathophysiology. This includes the differences in how SARS-CoV-2 presents in adults compared to children. Why does SARS-CoV-2 affect some people more severely than others? Why are some people asymptomatic? From an epidemiology standpoint, we also need additional research to fully understand the stages of disease progression including infection, the incubation period, the symptomatic period and for those who recover or have SARS-CoV-2 antibodies, whether they are immune.Furthermore, we have only just scratched the surface when it comes to our understanding of the sequelae of SARS-CoV-2 infection. For example, we are starting to see a new clinical entity called Multisystem Inflammatory Syndrome in Children (MIS-C) that follows SARS-CoV-2 infection. MIS-C is still very poorly understood in terms of why it occurs and how we should best clinically manage it. as physicians. With additional knowledge about these aspects of SARS-CoV-2, we will hopefully more effectively develop targeted treatments, vaccines and public health strategies to contain the spread of this virus.

GC: What are your thoughts about the ways clinicians and other researchers are collecting and disseminating information about COVID-19?

HST: There is currently a significant health communications challenge in how we can quickly and effectively communicate the results of scientific studies (that may sometimes only contain imperfect or incomplete information) to the general public in a way that is understood, accepted and can hopefully lead to effective and sustainable policy or behavior changes in real-time. A huge barrier that we have already seen is in the wearing of masks. While science has shown that this practice is effective in containing the spread of SARS-CoV-2, and most people are aware of this information, it is difficult to convince everyone to wear masks. From my experience, I think that clinicians have been doing a great job at collecting and disseminating information with each other via social media, emails and conferences regarding the different presentations and workup of COVID-19 they have seen and how they are tackling and troubleshooting systems-level issues. Medical journals have also fast-tracked COVID-19publications to help communicate new medical information as quickly as possible. I think that an area of improvement would be to have increased collaboration across fields between clinicians, researchers, public health and communications/public relations professionals to improve the messaging to the general public. We need to ensure that our public health message is consistent, easily understood and provides feasible action steps for the public to take in response. We live in a time when there is a large amount of information that is being transmitted at dizzyingly fast speeds and sometimes carries conflicting messages. We should harness the power of social media to help us disseminate thoughtfully designed public health messages quickly.


GC: You're now a rising third year fellow (congratulations). What is it like to be training during a pandemic?

HST: Training during a pandemic has shown me both successes and failures in terms of how governments and hospitals respond to disasters. With regard to COVID-19, I have learned a lot about how hospitals and physicians cope with uncertainty in hospital resources utilization (including personal protective equipment, hospital beds and ventilators), and the treatment and management of patients with a new disease entity using our prior understanding of human physiology. I have also seen how different healthcare workers respond to the constant stress of worrying about personal risk of infection to themselves and their loved ones, and how they have gone above and beyond to take care of each other during these trying times. Through these observations, I have gained insight into howI want to conduct myself as an attending and leader of my ED team in the future.


GC: Do you suspect this pandemic will result in permanent changes to the practice of pediatric emergency medicine?

HST: Yes! As physicians, I suspect that there will be permanent changes in our approach to personal protective equipment, ways that we think about personal risk of infection in relation to patient care, and how we triage patients including which patients can be seen via telehealth visits vs. in-person visits (and the value of a physical examination!). At the hospital systems level, I suspect that there will be changes in having better levels of preparedness or contingency planning for patient surges in volume and/or acuity, and ways to create more financially sustainable models of healthcare for future epidemics or pandemics. Nationally and globally, this pandemic has also forced us to think creatively about how personnel and resources, especially in emergency medicine, can be effectively mobilized to high-risk areas quickly when needed.

GC: Hoi See, thank you so much for sharing your experiences and perspectives!

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