key: cord-0843709-a6m9aatl
authors: Julian, Jeffrey A.; Mathern, Douglas R.; Fernando, Dinali
title: Idiopathic Thrombocytopenic Purpura and the Moderna Covid-19 Vaccine – A Case Report
date: 2021-02-12
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2021.02.011
sha: e9b10811656028d024c95496e6af44a0f8e340f1
doc_id: 843709
cord_uid: a6m9aatl

nan

To the Editor:

Recently, it was reported that a physician developed petechiae three days after receiving the Pfizer-BioNTech Covid-19 vaccine, was diagnosed with idiopathic thrombocytopenic purpura (ITP), and ultimately died of a cerebral hemorrhage. 1 Here, we report a case of ITP in a 72-year old woman one day after receiving the first dose of the Moderna Covid-19 vaccine.

The day after receiving her vaccination, the patient awoke with a rash, spontaneous oral bleeding, and headache. She denied any history of easy bruising or abnormal bleeding. Her medical history included gout, type 2 diabetes mellitus, and seasonal contact dermatitis. She denied any new medications or changes to her allopurinol and sitagliptin within the last five years. She denied any family history of autoimmune disorders.

On exam, she had diffuse petechiae across her arms, legs, and abdomen, and hemorrhagic bullae of the gingival mucosa. Labs were notable for an initial platelet count of 12,000 per µL, decreasing to 1,000 per µL within 12 hours of arrival. Other laboratory tests are as shown in Table 1 . Of note, normal prothrombin time, activated partial-thromboplastin time, d-dimer, and fibrinogen, ruled out disseminated intravascular coagulation. Further, normal hemoglobin, haptoglobin, lactate dehydrogenase, and peripheral smear without schistocytes were inconsistent with hemolytic uremic syndrome or thrombotic thrombocytopenic purpura. Viral studies, including hepatitis A, B, and C, Epstein-Barr virus, human immunodeficiency virus, cytomegalovirus, influenza A and B, and SARS-CoV-2 revealed no evidence of current or prior infection. Parvovirus IgG but not IgM antibodies were present, indicating prior resolved infection.

Antinuclear antibody titers were undetectable, making rheumatic etiology less likely.

The patient received an initial 40-mg intravenous dose of dexamethasone, and additional doses of 20 mg per day for three days thereafter. Intravenous immunoglobulin, aminocaproic acid, and rituximab were administered, and she received multiple platelet transfusions.

However, her platelets continued to fluctuate between 1,000 and 40,000 per µL. Non-contrast computed tomography of the head was without evidence of intracranial bleeding. Her course was complicated by multiple episodes of melena.

ITP post-vaccination has been reported in the MMR vaccine, 2 and has been associated with the use of attenuated vaccines and vaccine adjuvants, with one review identifying 45% of druginduced ITP occurring post-vaccination. 3 While hypersensitivity reactions are a known adverse event related to mRNA Covid-19 vaccines, 4 this is to our knowledge the second known case of acute ITP following administration. 

Death of a doctor who got Covid shot is being investigated

Vaccine administration and the development of immune thrombocytopenic purpura in children

ITP following vaccination

Maintaining Safety with SARS-CoV-2 Vaccines