Severe, Refractory Immune Thrombocytopenia Occurring After SARS-CoV-2 Vaccine

U.S, 6 April 2021, Helms et al, Journal of Blood Medicine

Summary

We report a 74-year-old man who developed refractory thrombocytopenia within one day of receiving the Moderna SARS-CoV-2 vaccine. Several hours after vaccination, he developed significant epistaxis and cutaneous purpura. Severe thrombocytopenia was documented the following day, and he developed extremity weakness and encephalopathy with facial muscle weakness.

Over a 14-day period, thrombocytopenia was treated first with high dose dexamethasone, intravenous immunoglobulin, platelet transfusions, rituximab, plasma exchange (for presumed acute inflammatory demyelinating polyneuropathy (AIDP)), and four daily doses of the thrombopoietin receptor agonist (TPO-RA) eltrombopag (Promacta™), without a platelet response. Three days later, he received the TPO-RA romiplostim (Nplate™). Five days later, his platelet count began to rise and by post-vaccination day 25, his platelet count was in the normal range. Thrombocytopenia was refractory to frontline and second-line treatment. The eventual rise in his platelet count suggests that one or both TPO-RAs may have impacted platelet recovery.

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Post-vaccination platelet count.
Abbreviations: Dex, dexamethasone; Methyl, methylprednisolone; PT, platelet transfusion; IVIG, intravenous immunoglobulin; Ritux, rituximab; Eltrom, eltrombopag; Romi, romiplostim; PLEX, plasma exchange.

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