key: cord-0990591-9ugfhnze
authors: Angelo, Gardellini; Francesca, Guidotti; Elena, Maino; Sara, Steffanoni; Michelle, Zancenella; Mauro, Turrini
title: Severe immune thrombocytopenia after COVID-19 vaccination: Report of four cases and review of the literature
date: 2021-10-07
journal: Blood Cells Mol Dis
DOI: 10.1016/j.bcmd.2021.102615
sha: f782b761021308658a02a5a5a5eed53414342ca1
doc_id: 990591
cord_uid: 9ugfhnze

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raising concern about this possible complication and the management of patients with preexisting autoimmune cytopenias.

Herein we report four cases of ITP following COVID-19 vaccination (Table I) and all patients obtained complete response to treatment [1] . Also Pfizer-Biontech mRNA vaccine have been related to ITP: a platelet drop was described 3-18 days after administration of first or second dose and generally successfully treated with steroids with or without IVIG. Some had a previous diagnosis of ITP with stable platelet count at the moment of vaccine administration [2] [3] [4] .

Moderna vaccine-related ITP cases have been described, in a case severe and refractory prompting therapy with dexamethasone, IVIG, platelet transfusions, rituximab and eltrombopag [4, 5] . Reports of ITP following Johnson and Johnson COVID-19 vaccine are present in literature too [6] . An overall incidence of thrombocytopenia, including ITP, after vaccination with Pfizer-BioNTech COVID-19

Vaccine or Moderna COVID-19 Vaccine is described in the case-series reported to the Vaccine Adverse Event Reporting System published on June 2021. The reporting rate of thrombocytopenia was 0.80 per million doses for both vaccines, less than the annual incidence rate of 3.3 ITP cases per 100,000 adults [7] .

Our report describes four more cases of severe ITP following COVID-19 vaccination with both mRNA and adenoviral vector vaccine. Two patients had a new onset of severe ITP while two had a history of ITP but stable platelet values. Of note, while the first two were well managed with oral corticosteroids, in the latter two cases thrombocytopenia was more difficult to manage: they experienced relapses and one of them failed treatment with steroids, IVIG and eltrombopag, obtaining only partial remission with romiplostim. This, together with available literature data, underlies that hematologic monitoring in patients with ITP is advisable before and after vaccination [8] . To date, it is not defined which vaccine should be administered to patients who developed ITP after the first dose, as all of them (mRNA and adenoviral vector) have been linked to possible ITP: from our experience, it appears reasonable to complete vaccination carefully monitoring CBC in order to early recognize a platelet drop.

As vaccination against COVID-19 infection is still ongoing it is mandatory to collect more data and, waiting for more information and guidelines, it appears safer to pay attention to possible hemorrhagic events and carefully monitor patients with previous history of ITP as their management could be J o u r n a l P r e -p r o o f demanding and difficult as showed by our experience. Anyway, there are no doubts that, considering mortality and morbidity risk after COVID-19 infection, benefits of vaccination outweigh the risk to develop ITP as a vaccine-related adverse event.

Immune Thrombocytopenic Purpura after vaccination with COVID

Vaccine (ChAdOx1 nCov-19). Blood

Acute Immune Thrombocytopenia (ITP) Following COVID-19 Vaccination in a Patient With Previously Stable ITP. Open Forum Infect Dis

A Case of Immune Thrombocytopenia After BNT162b2 mRNA COVID-19 Vaccination

Thrombocytopenia following Pfizer and Moderna SARS-CoV-2 vaccination

Refractory Immune Thrombocytopenia Occurring After SARS-CoV-2 Vaccine

COVID-19 vaccination associated severe immune thrombocytopenia

Thrombocytopenia including immune thrombocytopenia after receipt of mRNA COVID-19 vaccines reported to the Vaccine Adverse Event Reporting System (VAERS)

SARS-CoV-2 vaccination in patients with autoimmune cytopenias: the experience of a reference center