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Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 125-127

SARS-CoV-2 infection evolving into aplastic anaemia: An unusual presentation of COVID-19 in the paediatric age group

Department of Pathology, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, India

Date of Submission01-Jun-2021
Date of Decision02-Mar-2022
Date of Acceptance05-Apr-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Dr. Vijay Kumar
Department of Pathology, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, New Delhi - 110 001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmrp.cmrp_55_21

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Aplastic anaemia can develop due to various viral infections. However, SARS-CoV-2 infection evolving into aplastic anaemia is rarely seen. Here, we present a case of a 6-year-old boy who presented with epistaxis and rashes all over the body after recovery from COVID-19. Peripheral blood smear examination revealed pancytopenia with neutropenia and also reticulocytopenia. Bone marrow biopsy showed a hypoplastic marrow (cellularity of 10%), leading to a diagnosis of aplastic anaemia.

Keywords: Aplastic anaemia, COVID-19, pancytopenia, SARS-CoV-2

How to cite this article:
Bhatia A, Kumar V, Yadav A. SARS-CoV-2 infection evolving into aplastic anaemia: An unusual presentation of COVID-19 in the paediatric age group. Curr Med Res Pract 2022;12:125-7

How to cite this URL:
Bhatia A, Kumar V, Yadav A. SARS-CoV-2 infection evolving into aplastic anaemia: An unusual presentation of COVID-19 in the paediatric age group. Curr Med Res Pract [serial online] 2022 [cited 2023 May 30];12:125-7. Available from: http://www.cmrpjournal.org/text.asp?2022/12/3/125/349296

  Introduction Top

The coronavirus disease-2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).[1] It was first reported in China and has since then rapidly spread throughout the world.[2] COVID-19 has been seen to occur across all age groups. In children, the infection is usually asymptomatic or may be mild to moderate in intensity, with most children recovering without any sequelae.[3] However, the presence of various mutants, especially the Delta variant (B.1.617.2), which was prevalent in India during May 2021, has changed our understanding about its clinical course.[4] The present case is of a 6-year-old child who presented with fever and pancytopenia as the primary manifestations of COVID-19 (during the Delta wave), which evolved into aplastic anaemia.

  Case Report Top

A 6-year-old male child presented to the hospital with epistaxis and rashes all over the body for 2 weeks. The child also had one episode of blood in stools. He also had a history of recovery from COVID-19 two weeks prior to onset of the presenting complaints. The patient had presented at that time with fever and malaise and his rapid antigen test was positive for SARS-CoV-2. His routine investigations had revealed pancytopenia, with a haemoglobin of 5.6 gm/dl and a total leucocyte count of 2000/cumm with an absolute neutrophil count of 160/cumm; and platelets were 43,000/cumm [Figure 1]a. A previous complete blood count of the patient before the development of COVID-19 was, however, not available. The patient was transfused with two units of platelets and was managed symptomatically for COVID-19. After a period of isolation of 2 weeks, his repeat test for COVID-19 (reverse transcription-polymerase chain reaction) was negative. However, pancytopenia with neutropenia persisted and he presented with epistaxis. His corrected reticulocyte count was 0.3%. Bone marrow examination was done, where the aspirate was completely hemodiluted. However, bone marrow biopsy revealed a markedly hypocellular marrow with a cellularity of 10%, with the cellular component of marrow being replaced by fat spaces [Figure 1]b and [Figure 1]c. Cells mainly comprised few lymphocytes and plasma cells [Figure 1]d and occasional haematopoietic cells. Based on these findings, a diagnosis of aplastic anaemia was made. The patient was evaluated for other viral markers (Parvovirus B19 IgG/IgM, EBV-V capsid IgG, HBsAg and HIV antibodies), which were negative.
Figure 1: (a) Peripheral blood smear of the patient showing pancytopenia (Leishman stain; ×400). (b and c) Bone marrow biopsy showing hypocellular marrow with a cellularity of 10% (H and E; ×40 and ×100, respectively). (d) Bone marrow biopsy showing replacement of haematopoietic cells with fat spaces and few lymphocytes and plasma cells (H and E; ×400)

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  Discussion Top

The present case describes an interesting aspect of SARS-CoV-2 evolving into aplastic anaemia. COVID-19 among children commonly presents with symptoms ranging from completely asymptomatic to fever and symptoms of acute upper respiratory tract infection such as cough, sore throat and shortness of breath. In severe cases, patients may have respiratory failure, shock and coagulopathy.[3],[5] In few cases, features similar to those seen in Kawasaki disease, a multisystem inflammatory syndrome in children, may be seen.[6] Pancytopenia is usually not seen in patients with COVID-19.[7],[8] The usual haematological manifestation is lymphopenia; however, in severe cases, thrombocytopenia may be seen.[9]

In the present case, initially, the patient presented with fever and pancytopenia. The pancytopenia persisted even after recovery from COVID-19, evolving into aplastic anaemia. Aetiology for acquired aplastic anaemia includes various viral infections, including EBV, HIV and parvovirus B19.[10] However, serology for all these viral markers was negative in the present case. An antigenic epitope on myelocytes can be exposed after viral infections, which can lead to the production of autoantibody, further leading to the destruction of the haematopoietic cells. According to various studies, the angiotensin-converting enzyme 2 receptor, which is the target of the SARS-CoV-2, has been identified in the bone marrow, although at a lower level.[7],[11] Therefore, it is possible that direct infection of haematopoietic cells could lead to bone marrow suppression. COVID-19 is also known to cause an increase in pro-inflammatory cytokines. Few studies have also implied the role of these pro-inflammatory cytokines in the development of secondary haemophagocytic lymphohistiocytosis in some cases of severe COVID-19. It is also known that certain cytokines, like the interferons and tumour-necrosis factor-α, can affect the haematopoietic stem cells, thereby impairing haematopoiesis.[7],[12] This might be the reason behind the bone marrow suppression in this case. The other causes of acquired aplastic anaemia were also ruled out in the present case. There was no history of any drug intake before COVID-19 infection. Furthermore, there were no clinical features (skeletal deformities, congenital disabilities, etc.) to suggest an inherited bone marrow failure syndrome.

Even though post-viral aetiology is a known cause for the development of aplastic anaemia, the role of SARS-CoV-2 remains unclear. Till date, only two studies have described the development of aplastic anaemia in COVID-19. In the case reported by Figlerowicz et al.,[13] the patient was a 6-year-old girl who developed fever and sore throat along with pancytopenia and was diagnosed with COVID-19. The patient was transfused with convalescent plasma, following which elimination of SARS-CoV-2 was noted, which was confirmed by the SARS-CoV-2 RNA test in the nasopharyngeal swab. However, aplastic anaemia persisted in the patient, similar to the present case. Another case by Adel and Magdy[5] showed the development of aplastic anaemia in a case of COVID-19 in an infant.

The present case was managed symptomatically and was given packed red blood cell and platelet transfusions. However, pancytopenia and reticulocytopaenia still persisted in the child even after a month of symptomatic treatment. Unfortunately, the patient was lost to further follow up.

  Conclusion Top

As COVID-19 is a relatively new entity, we do not have the complete information regarding its clinical course. With the presence of new mutants, data are still evolving regarding its course and implications. Development of aplastic anaemia after SARS-CoV-2 infection is extremely rare, with only two case reports being published in the literature. Although rare, it is imperative to know about this entity so as to not miss any case of COVID-19 and to individualise the treatment accordingly.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.  Back to cited text no. 2
Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiology of COVID-19 among children in China. Pediatrics 2020;145:e20200702.  Back to cited text no. 3
European Centre for Disease Prevention and Control. Emergence of SARS-CoV-2 B.1.617 Variants in India and Situation in the EU/EEA–11 May, 2021. Stockholm: ECDC; 2021.  Back to cited text no. 4
Adel M, Magdy A. SARS-CoV-2 infection in an infant with non respiratory manifestations: A case report. Gaz Egypt Paediatr Assoc 2021;69:3.  Back to cited text no. 5
Chiotos K, Bassiri H, Behrens EM, Blatz AM, Chang J, Diorio C, et al. Multisystem inflammatory syndrome in children during the coronavirus 2019 pandemic: A case series. J Pediatric Infect Dis Soc 2020;9:393-8.  Back to cited text no. 6
Zhao Y, He J, Wang J, Li WM, Xu M, Yu X, et al. Development of pancytopenia in a patient with COVID-19. J Med Virol 2021;93:1219-20.  Back to cited text no. 7
Hersby DS, Do TH, Gang AO, Nielsen TH. COVID-19-associated pancytopenia can be self-limiting and does not necessarily warrant bone marrow biopsy for the purposes of SARS-CoV-2 diagnostics. Ann Oncol 2021;32:121-3.  Back to cited text no. 8
Al-Samkari H, Karp Leaf RS, Dzik WH, Carlson JC, Fogerty AE, Waheed A, et al. COVID-19 and coagulation: Bleeding and thrombotic manifestations of SARS-CoV-2 infection. Blood 2020;136:489-500.  Back to cited text no. 9
Young NS, Kaufman DW. The epidemiology of acquired aplastic anemia. Haematologica 2008;93:489-92.  Back to cited text no. 10
Li MY, Li L, Zhang Y, Wang XS. Expression of the SARS-CoV-2 cell receptor gene ACE2 in a wide variety of human tissues. Infect Dis Poverty 2020;9:45.  Back to cited text no. 11
Clapes T, Lefkopoulos S, Trompouki E. Stress and non-stress roles of inflammatory signals during HSC emergence and maintenance. Front Immunol 2016;7:487.  Back to cited text no. 12
Figlerowicz M, Mania A, Lubarski K, Lewandowska Z, Służewski W, Derwich K, et al. First case of convalescent plasma transfusion in a child with COVID-19-associated severe aplastic anemia. Transfus Apher Sci 2020;59:102866.  Back to cited text no. 13


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