COVID-19 vaccination associated severe immune thrombocytopenia

Abstract

Background Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 has emerged as a deadliest global pandemic after its identification in December 2019 in Wuhan, China resulting in more than three million deaths worldwide. Recently FDA issued emergency authorization for three vaccines for prevention of COVID-19. Here in, we report three cases of severe immune thrombocytopenia (ITP) following COVID-19 vaccination and their clinical course. Case presentations Case #1: 53 year old male with past medical history of Crohn’s disease was admitted for myalgias and diffuse petechial rash 8 days after receiving second dose of Pfizer-BioNTech COVID-19 vaccine. A complete blood test showed a platelet count of 2 × 109/L. Patient did not have a prior history of thrombocytopenia and other causes of thrombocytopenia were ruled out by history and pertinent lab data. He received two doses of intravenous immunoglobulin and oral dexamethasone for 4 days resulting in normalization of platelet counts. Case #2: 67 year male with past medical history of chronic ITP in remission was admitted for melena 2 days after receiving his first dose of Pfizer-BioNTech COVID-19 vaccine. A complete blood test showed a platelet count of 2 × 109/L. Physical exam showed generalized petechiae. There was no history of recent flares of ITP and patient had normal platelet counts following his splenectomy 4 years ago. He received two doses of IVIG and oral dexamethasone for 4 days with gradual improvement in platelet counts. Case #3: 59 year old female with past medical history of chronic ITP secondary to SLE was admitted for bloody diarrhea 2 days after receiving her first dose of Johnson and Johnson COVID-19 vaccine. Physical exam was unremarkable. A complete blood test showed platelet count of 64 × 109/L which dropped to 27 × 109/L during hospital course. She received oral dexamethasone for 4 days with improvement in platelet counts. Conclusion COVID-19 vaccination induced ITP has been recently acknowledged. However, given very few cases and limited data, currently there are no guidelines for management of ITP caused by COVID-19 vaccine as well as vaccination of people with predisposing conditions.

SARS‐CoV‐2 vaccination in patients with autoimmune cytopenias: The experience of a reference center

“…They are marked by several relapses often triggered by immune‐activating events (infections, traumas, surgery) including vaccines. 1 , 2 Some reports of ITP and AIHA exacerbations after SARS‐CoV‐2 vaccines (mRNA vaccines Pfizer‐Biontech and Moderna, and Adenovirus based vaccine AstraZeneca) have been described, 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 but evidence‐based indications for their management are lacking.…”

“… 14 , 15 More data are available for ITP, including 21 patients (15 Pfizer, four Moderna, two Johnson&Johnson) from nine case reports/series. 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 Most patients rapidly improved with steroids or adjustment of ongoing treatment, including TPO‐RA that may reduce the need of immunosuppression. The latter may abate the immune response to vaccines, 17 although further studies are needed to assess vaccination efficacy under immunosuppressive treatment.…”

Immune Thrombocytopenia Induced by the Chimpanzee Adenovirus-Vectored Vaccine against SARS-CoV-2 Infection

“…Moreover, there were other cases of COVID-19 vaccination reporting immune thrombocytopenia (ITP) with two cases induced by BNT162b2, Pfizer-BioNTech, and one case induced by Ad26.COV2.s COVID-19 vaccine [7]. In another case report, these were mainly associated with mRNA vaccines (BNT162b2, Pfizer-BioNTech and mRNA-1273, Moderna COVID-19 vaccine) [8].…”

Vincristine therapy for severe and refractory immune thrombocytopenia following COVID-19 vaccination

“…Thrombocytopenia after COVID-19 vaccination accompanied by thrombosis is usually reported as thrombosis with thrombocytopenia syndrome or vaccine-induced immune thrombotic thrombocytopenia [ 3 ], which is associated with anti-PF4 antibodies and usually develops after inoculation with adenoviral vector-based vaccines. Further, ITP after COVID-19 vaccination usually presents with severe thrombocytopenia and hemorrhagic symptoms [ 1 , 4 – 7 ]. The present case was considered vaccine-associated ITP, established by the presence of serum anti-glycoprotein IIb/IIIa antibody, one of the platelet autoantibodies [ 8 ].…”

“…Although most cases of COVID-19 vaccine-related ITP were responsive to initial treatment with steroids and/or IVIG [ 1 , 4 – 7 ], some patients died of intracranial hemorrhage according to reports from the Vaccine Adverse Event Reporting System [ 9 ]. Although the present case showed a very high risk of life-threatening hemorrhage, vincristine yielded a rapid response.…”