COVID-19 Vaccination Associated Severe Immune Thrombocytopenic Purpura

Introduction

Immune thrombocytopenic purpura (ITP) is a known adverse effect of vaccinations including measles, mumps, rubella (MMR), influenza, hepatitis B, and diphtheria-tetanus-pertussis. The pathogenesis is not well understood and is probably related to molecular mimicry. There are few reported cases of chronic ITP exacerbation after receiving COVID-19 mRNA vaccines. However severe ITP in a young male with no prior hematological diagnosis has rarely been reported. We are reporting one such case.

Case Description

A 19-year-old-male with no previous medical history presented with gingival bleeding and skin petechiae on the chest and lower extremities of two weeks duration. He denied any recent infections, new medications, drug abuse, alcohol intake, exposure to chemicals, multiple sexual partners, or history of easy bleeding or bruising. One week prior to presentation, he received his second vaccination of COVID m-RNA vaccine one week prior to developing symptoms, with no immediate reactions. On exam, he had petechiae on his chest and lower extremities, with no other notable findings. Complete blood count (CBC) revealed isolated thrombocytopenia with a platelet count of 7000 per microliter (mcL), and a peripheral smear which showed enlarged platelets with no evidence for platelet clumping, blasts or dysplastic cells. Work-up for thrombocytopenia including nutritional deficiencies, infections and other etiologies were unrevealing. Subsequently he was diagnosed with ITP. He was treated with 3 doses of intravenous immunoglobulin (IVIG) and dexamethasone 40 milligrams (mg) when his platelet counts recovered to 105,000 per mcL. He was discharged with prednisone 40 milligrams daily. At 1 week follow up, his platelets remained stable at 118,000 per mcL when his steroids were tapered off.

Discussion

ITP post vaccination is a known but rare phenomenon. COVID-19 vaccination related ITP has rarely been reported, and the management/outcomes of these cases is not well established in literature. Further, the relationship between COVID-19 vaccination and thrombocytopenia remains unclear, whether it is casual or just coincidental. The Centers for Disease Control and Prevention and US-Food and Drug Administration (FDA) have recently announced that the incidence of ITP after COVID-19 vaccination was not higher than that of the general population.

ITP associated with vaccination varies in severity but generally responds well to typical ITP therapies, such as corticosteroids and IVIG. More studies are needed to determine the best treatment options for these patients.

No relevant conflicts of interest to declare.