Gustavo Avila, MD
Chief Resident Physician
JFK Medical Ctr/University of Miami, United States
Disclosure information not submitted.
Title: COVID Vaccine induced complicated ITP
Case Report Body:
Introduction: With the ongoing COVID pandemic, physicians are being questioned about potential serious side effects & the risk of these developing. Currently, the most serious to be observed in the US include: anaphylaxis (2-5 per million), TTS (38 from 12.8 million J&J and 2 from 321 million Moderna), & myocarditis (1,047 from all vaccinations). As of 2/2/21, there was < 1 case per million of ITP (17 from over 20 million vaccinations). In this case report, we present a 53 yr F w/ HLD with ITP complicated by spontaneous intracranial hemorrhage. To our knowledge only 1 other case like this has occurred in the US.
Description: 48 hours after receiving the Moderna vaccine, the patient had complaint of headache, bleeding gums on brushing her teeth, & petechiae. CT Head was unremarkable. Labs revealed severe thrombocytopenia with platelet count 2000 and Hgb 13. PT, PTT & INR were all normal. Autoimmune workup showed ANA positive and weakly positive for Anti-SSA. She was transfused platelets, given pulse dose steroids, and IVIG. Post transfusion, platelet count had fallen to 0. On day 4, the PLT count was 1000 despite multiple transfusions and ongoing steroid therapy and she had a worsening headache and new onset rectal bleeding. A CT brain and MRI showed two 0.4cm hemorrhagic foci in the right temporal and left frontal lobes. Fortunately, she had no neurological deficits. Platelet transfusion continued. Hgb had fallen from 13 to 7.6. There was no concern for MAHA as peripheral smear did not show abnormal RBC morphology and LDH and haptoglobin were normal. On day 5, PLT count was 9000 and Nplate (thrombopoietin receptor agonist) was started. On day 6, platelet count had finally risen to 35,000 and 132,000 on day 8. PLT count 3 days later was 326,000, her previous baseline.
Discussion: Current recommendations for ITP are glucocorticoids and IVIG as the first line of therapy for minor bleeding w/ platelet count < 20,000. If improvement is not seen, then a TPO-agonist is initiated. This gives rise to some interesting questions for acute ITP. Would initiating apheresis on presentation instead of IVIG decrease the likelihood of brain hemorrhage? Acute ITP may become more common as COVID-19 brings new variants and requires more vaccinations/boosters. Further discussion on these topics may yield improvements in outcome.