Immune Thrombocytopenic
Purpura After Receiving AstraZeneca Coronavirus Disease-2019 Vaccine in
A Patient with A Past History of the Same Disease: A Case Report
Saba Seyedia, Shadan
Navidb,Zahra
Saadatianc*
- Department of Medical laboratory sciences, School of Medicine, Gonabad
University of Medical Sciences, Gonabad, Iran.
- Department of Anatomy, Faculty
of Medicine, Social Determinants of Health Research Center, Gonabad
University of Medical Science, Gonabad, Iran.
- Department of Physiology, Faculty of Medicine, Infectious Diseases
Research Center, Gonabad University of Medical Sciences, Gonabad,
Iran.
Corresponding author: Zahra Saadatian. Department of
Physiology, School of Medicine, Gonabad University of Medical Sciences,
Gonabad, Iran.
z.saadatian@yahoo.com
saadatian.z@gmu.ac.ir
key words: AstraZeneca, immune thrombocytopenic purpura, ChAdOx1
nCoV-19, AZD1222, case report, covid-19
Immune Thrombocytopenic Purpura After Receiving AstraZeneca
Coronavirus Disease-2019 Vaccinein A Patient with A Past
History of the Same Disease: A Case Report
Key Clinical Message: Immune thrombocytopenic purpura (ITP) is
an autoimmune disease characterized by a low platelets count, petechiae,
purpura, and conjunctival hemorrhage. In this paper, we present a
relapse of ITP in an Iranian 31-year-old woman as a potential
complication of the AstraZeneca vaccine.
Introduction
Severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2)classified
in the coronaviridae family is characterized as a pandemic, and the
virus is spreading increasingly worldwide
(1). Accelerated efforts to
develop safe and effective vaccines commenced immediately
to control this pandemic (2).
AstraZeneca/Oxford’s AZD1222, a vaccine candidate that entered phase 1
clinical trial in mid-May 2020, was injected intramuscularly in two
doses to the participants aged 18-55 years at least 28 days intervals
(3). Early observations insinuate that exposure to the AstraZeneca
COVID-19 vaccine might trigger the expression of antiplatelet
antibodies, resulting in a condition with thrombocytopenia and venous
thrombotic events (e.g., intracranial venous sinus
thrombosis) (4). ITP is a rare
autoimmune disorder with reduced circulating platelets and occasionally
impaired megakaryopoiesis (5).
Platelets, as the smallest cell
fragments of the human blood, are central players in the processes of
hemostasis and thrombosis (6). The normal human platelets count ranges
from 150 × 109 to 450 × 109platelets per liter of blood, and its insufficient count elevates the
risk of spontaneous bleeding (7).
In this case report, we confer the
relapse of immune thrombocytopenic purpura after the first vaccination
with ”the COVID-19 vaccine AstraZeneca” the first time.
Case history
An Iranian 31 years old female with a previous history of ITP presented
with progressive, vast, and diffuse
ecchymosis, increased scattered
petechia purpura, and fatigue three weeks after receiving the first dose
of AstraZeneca. As a result of symptoms persistence, she was referred to
an outpatient laboratory to evaluate her complete blood count (CBC) 28
days after vaccine injection. CBC result showed a platelet count of
<2000 / Mm3 and demonstrated ITP relapse.
Considering her previous medical history, she had experienced a platelet
decrease (9000/ Mm3 platelet count) when she was 25.
On that occasion, various tests including autoimmune diseases tests
(rheumatoid arthritis, lupus, and antiphospholipid syndrome), and bone
marrow aspiration had ruled out other causes of platelets decrease and
confirmed ITP. She had been treated with dexamethasone injection for
three days in the hospital and taking prednisolone pills for six months.
She had periodic checkups of CBCs, and the range of platelets was
different between 210-100× 103/ Mm3.
The last CBC monitoring was carried out in 2019.
Differential diagnosis, investigations and treatment
After the COVID-19 pandemic, nevertheless, our case did not perform
routine checkups, nor did she have any symptoms of platelet depletion
such as scattered ecchymoses and fatigue before receiving the vaccine.
Since she previously had ITP, she was given high dose dexamethasone and
then saw a physician who recommended hospital admission when her
platelet count came back at 25000/ Mm3. Other
hematological, biochemical, and immunological tests did not reveal any
other disease except intensive thrombocytopenia (Table 1).
In addition, her CRP was negative, and ESR was normal, ruling out any
infection and inflammation existence that could be related to other
causes of ITP. In the hospital, she received intravenous immunoglobulin
(IVIG)(50gr) and dexamethasone (40mg) for four days, and after her
platelet count reached above 100× 103/
Mm3, she was discharged. On completion of
treatment, she had been
prescribed 40mg per day of dexamethasone for four days at intervals of
two weeks with periodic monitoring of her CBC. Figure1 illustrates
platelet counts considering before and after disease diagnosis and
treatment.
Outcome and follow-up
Considering the persistence of platelet count in the normal range and
with due attention to the previous finding that expresses the benefit of
vaccination is more than its risks (8),
our
case received the next dose of AstraZeneca vaccine three months after
the first dose and about 1.5 months after treatment completion.
Nevertheless, her platelet stability did not collapse
(210× 103/ Mm3), nor did she present
signs of ITP. Moreover, she got vaccinated with the same vaccine for the
third time about six months later and she did not experience any side
effects (platelet count:
213× 103/
Mm3).
Discussion
Immune thrombocytopenic purpura is an autoimmune blood disorder
characterized by platelet reduction followed by petechiae, purpura,
conjunctival hemorrhage, or other types of mucocutaneous bleeding
(9). The incidence of the disorder
is about 100 in 1milion people each year, and most of the patients are
children (9). However, it is developed in acute form lasting about six
months in children and adults. It is generally chronic and occurs more
in women than men (9). Early detection of ITP is critical because
intracranial hemorrhage could be the major cause of fatal bleeding in
these patients (9). Immune
thrombocytopenic purpura usually appears following autoimmune conditions
and viral infections (6). In addition, considering many reports, ITP
could be manifested as a result of vaccines (6).
More than 100 COVID-19 vaccine
candidates are currently under development, and the number is increasing
(10). Various types of vaccines are classified into recombinant protein
vaccines, mRNA-based vaccines, DNA- based vaccines, and vector-based
vaccines (10). The AstraZeneca vaccine is from the adenovirus category,
and the vaccine candidate is ChAdOx1 nCoV-19 (10).
The advantages of this vaccine are
a high transfection efficacy, as the viral vector imitates the natural
infection process. Disadvantages are that the vaccine may promote
thrombocytopenia and intracranial venous sinus thrombosis (4). In
addition, there are some reports of post vaccine ITP (11).
Previously, Koch and his colleagues described a 41 years old male with
ITP, 14 days after the first dose of vaccination with AstraZeneca from
Germany (5). Furthermore, there were other reports of ITP three and two
days after receiving AstraZeneca in a Korean 66 years old female and an
Iraqi 25 years old male respectively (16, 17). In a case series, 17
cases were reported with secondary ITP related to AstraZeneca. All of
them had onset within 28 days after vaccine administration, but one case
diagnosed with ITP after 78 days (11).
According to the information from previous vaccines, various mechanisms
could trigger ITP after vaccination, such as impairment regulation of T
cells, elevated pro-inflammatory cytokine production, and increased
macrophage-mediated eradication (12). Although the mechanism of
vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT)
post-AstraZeneca vaccine has been elucidated in some research (13),
there isn’t much known about the
mechanism of immune thrombocytopenia post-AstraZeneca vaccine. It seems
IgG antibodies against platelet factor 4 (PF4) are responsible for VITT
(14). On the other hand, IgG is the principal antibody in ITP, which is
opposed to platelet membrane glycoproteins such as GPIIb/IIIa (15).
Moreover, spike protein is the antigenic target for vaccines such as
SARS-CoV-1 and MERS (15). But it’s unclear whether spike protein and the
PF4 have any cross-reactions with each other (15). Altogether, more
information is required to determine if the underlying mechanism of
other vaccines can be the same as post-COVID19 vaccine ITP.
In this paper we introduced an Iranian 31 years old female with a past
history of ITP who developed petechia purpura and ecchymosis following
AstraZeneca first dose administration and diagnosed with
thrombocytopenia. After completion of treatment the next doses of the
same vaccine are injected and there were no side effects. To the best of
our knowledge, this paper may be the first case report presenting a
patient with a past history of vaccine complication receiving the second
and booster doses of the same vaccine without any incident.
Conclusion
Some patients with past history of ITP may be more susceptible to immune
thrombocytopenia from drugs or inciting agents as well as AstraZeneca
Coronavirus Disease-2019 Vaccine. Physicians should always be cautious
administering new agents to ITP patients since that disorder, a prior
indicated altered immune response. In addition, measuring platelet count
before and after vaccine reception is suggested. Furthermore, it is
indispensable to pay attention to any early signs of ITP to primarily
manage the condition and prevent disease deterioration that could be
life-threatening.
Declarations
Ethics approval and consent to
participate
This study was approved by the ethics committee of the Infectious
Diseases Center, Gonabad University of Medical Sciences, Gonabad, Iran.
(IR.GMU.REC.1400.207).
Author contributions
Saba Seyedi: Conceptualization, Writing – original draft
Shadan Navid: investigation, data curation
Zahra Saadatian: Supervision, writing – review and editing
Acknowledgements
We would like to thank the patient for agreeing to share her clinical
information with the readers of this article.
Funding information
This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.
Conflict of interest statement
All authors have approved the manuscript for submission and have no
competing interests to declare.
Consent
Written informed consent was obtained from the patient for publication
of this case report.
Availability of data and material
Not applicable
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