Critical Care COVID-19 Patient with a Picture of Thrombotic Thrombocytopenic Purpura
  • Rehab AL-Ansari
    Adult Hematology Unit, Internal Medicine Department, KFMMC, Dhahran, Kingdom of Saudi Arabia
  • Mohanad Bakkar
    Internal Medicine Department, KFMMC, Dhahran, Kingdom of Saudi Arabia
  • Leena Abdalla
    Internal Medicine Department, KFMMC, Dhahran, Kingdom of Saudi Arabia
  • Khaled Sewify
    Critical Care Department, KFMMC, Dhahran, Kingdom of Saudi Arabia


Thrombotic thrombocytopenic purpura, COVID-19, plasma exchange, cytokine storm


Background: Thrombotic thrombocytopenic purpura (TTP) is an uncommon haematological disease which can occur at any age and may present with COVID-19. This case describes a COVID-19 complication associated with a presentation resembling TTP.

Case description: A 51-year-old man who had received a kidney transplant and was on immunosuppressant medication, was admitted to a critical care unit with severe COVID-19 pneumonia/acute respiratory distress syndrome (ARDS) which required intubation, mechanical ventilation and inotropic support. The course was complicated by the classic pentad of thrombocytopenia, intravascular haemolysis, acute kidney injury, neurological symptoms and fever, which prompted the diagnosis of probable TTP. After five sessions of therapeutic plasma exchange, the patient’s general status improved, he was weaned off mechanical ventilation and his renal panel and haemolytic markers normalized.

Conclusion: TTP is a life-threatening condition which requires urgent management with therapeutic plasma exchange. This case highlights some possible complications of COVID-19 generally and in immunocompromised patients specifically. The potential role of plasma exchange in COVID-19 patients without a positive diagnosis of TTP (the so-called ‘TTP resembling presentation’) is an area of further research.



  • Furlan M, Robles R, Galbusera M, Remuzzi G, Kyrle PA, Brenner B, et al. von Willebrand factor-cleaving protease in thrombotic thrombocytopenic purpura and the hemolytic-uremic syndrome. N Engl J Med 1998;339(22):1578–1584.
  • Hu B, Huang S, Yin L. The cytokine storm and COVID-19. J Med Virol 2020 Jun 27;10.1002/jmv.26232. doi: 10.1002/jmv.26232.
  • Xu P, Zhou Q, Xu J. Mechanism of thrombocytopenia in COVID-19 patients. Ann Hematol 2020;99(6):1205–1208.
  • Bomhof G, Mutsaers PGNJ, Leebeek FWG, Te Boekhorst PAW, Hofland J, Croles FN, et al. COVID-19-associated immune thrombocytopenia. Br J Haematol 2020;190(2):e61–e64.
  • Hindilerden F, Yonal-Hindilerden I, Akar E, Kart-Yasar K. Covid-19 associated autoimmune thrombotic thrombocytopenic purpura: report of a case. Thromb Res 2020;195:136–138.
  • Joly BS, Coppo P, Veyradier A. Thrombotic thrombocytopenic purpura. Blood 2017;129(21):2836–2846.
  • Kempton CL, Antun AG. Thrombotic thrombocytopenic purpura. In: Shaz BH, Hillyer CD, Gil MR, eds. Transfusion medicine and hemostasis. 3rd ed. Elsevier; 2019, p. 649–654. Available from
  • Hanlon A, Metjian A. Caplacizumab in adult patients with acquired thrombotic thrombocytopenic purpura. Ther Adv Hematol 2020;11:2040620720902904. Published online 2020 Feb 7. doi: 10.1177/2040620720902904.
  • Khamis F, Al-Zakwani I, Al Hashmi S, Al Dowaiki S, Al Bahrani M, Pandak N, et al. Therapeutic plasma exchange in adults with severe COVID-19 infection. Int J Infect Dis 2020;99:214–218.
  • Zhang L, Zhai H, Ma S, Chen J, Gao Y. Efficacy of therapeutic plasma exchange in severe COVID-19 patients. Br J Haematol 2020 May 26;10.1111/bjh.16890. doi: 10.1111/bjh.16890. Online ahead of print.
  • Views: 1435
    HTML downloads: 228
    PDF downloads: 598

    Published: 2020-12-15
    Issue: 2020: Vol 7 No 12 (view)

    How to cite:
    AL-Ansari R, Bakkar M, Abdalla L, Sewify K. Critical Care COVID-19 Patient with a Picture of Thrombotic Thrombocytopenic Purpura . EJCRIM 2020;7 doi:10.12890/2020_002143.

    Most read articles by the same author(s)