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Immune thrombocytopenic purpura associated with COVID-19 Pfizer-BioNTech BNT16B2b2 mRNA vaccine
Journal of the European Academy of Dermatology and Venereology ( IF 9.2 ) Pub Date : 2021-06-02 , DOI: 10.1111/jdv.17444
P K Krajewski 1 , J C Szepietowski 1
Affiliation  

A 74-year-old Caucasian male patient presented to Dermatology Department with multiple haemorrhagic blisters on oral and nasal mucosa and purpuric rash on lower extremities. The cutaneous lesions appeared for the first time a day before admission, firstly on patient's thighs and then spread to lower legs and forearms. Moreover, that morning patient woke up with blood on his pillow. According to the anamnesis, on the day preceding the appearance of the symptoms, the patient received first dose of Pfizer (New York, NY, USA) – BioNTech (Mainz, Germany) BNT16B2b2 mRNA vaccine. On admission, physical examination revealed multiple haemorrhagic blisters on oral and nasal mucous membranes of various size (Fig. 1a). Moreover, purpuric rash localized on lower legs, thigs and forearms was visible (Fig. 1b). At the injection site, an ecchymosis of 2 cm in diameter was observed (Fig. 1c). The patient did not report any subjective symptoms associated with mucous and cutaneous lesions. Besides hypertension, the patient did not suffer from any other chronic diseases. There was no history of abnormal bleeding or family history of coagulopathies. The performed laboratory examinations revealed severe thrombocytopenia (2*109/L), with normal clotting parameters. Normal d-dimers concentration permitted us to exclude the associated thrombosis. Based on clinical manifestation and laboratory tests, immune thrombocytopenic purpura associated with SARS-CoV-2 vaccine was diagnosed. The patient was transferred to Hematology Department, where, to the best of our knowledge, he was put on bolus injections of 40 mg of dexamethasone for the three consecutive days. Moreover, platelet transfusion was performed.

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Figure 1
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Mucosal haemorrhagic blisters (a), purpuric rash on lower extremity (b) and ecchymosis on patient's arm (c).

Immune thrombocytopenia (ITP) is an immune-mediated disease defined by a decrease in platelet count, typically without signs of leukopenia and anaemia, which may be a cause of a life-threatening bleeding.1 It may be idiopathic; however, it is usually caused by an infection with Epstein–Barr, varicella-zoster or influenza viruses. It can also occur after vaccine administration, especially measles-mumps-rubella (MMR), hepatitis A and B, diphtheria-tetanus-acellular pertussis (DTaP) and varicella.2 Recently, numerous ITP cases after COVID-19 ChAdOx1 vaccine were described.3 The adverse reactions lead to an international doubt in AstraZeneca vaccine. Specific guidelines for COVID-19 vaccine-induced thrombosis and thrombocytopenia (VITT) management have been proposed.3, 4 The appearance of immune thrombocytopenic purpura, after other COVID-19 vaccines, besides some press releases, has been rarely reported in the literature. Recent review by Lee et al.5 grouped nine patient with ITP after of BNT16B2b2 vaccine. Two of them presented with gum bleeding or buccal bullae, some of them developed petechiae, and only one suffered from disseminated purpuric rash.5 Only one patient presented with symptoms as early as the day after the vaccination; nevertheless, the majority of them reached similar platelet count as in our patient. A few patients with immune thrombocytopenic purpura without thrombosis associated with COVID-19 mRNA 1273 (Moderna) vaccine have also been described.6 The management of ITP in above-mentioned patients consisted of mainly systemic corticosteroids and platelet transfusions. To the best of our knowledge, this is the first case of immune thrombocytopenic purpura reported in dermatologic literature. Dermatologists should be aware of the possibility of the development of ITP with subsequent mucous and cutaneous lesions after COVID-19 vaccination, not only related to ChAdOx1 vaccine. Further observations will help in establishing the real risk of the development of immune thrombocytopenic purpura after particular COVID-19 vaccines.



中文翻译:

与 COVID-19 Pfizer-BioNTech BNT16B2b2 mRNA 疫苗相关的免疫性血小板减少性紫癜

一名 74 岁高加索男性患者因口腔和鼻粘膜多处出血性水疱和下肢紫癜性皮疹到皮肤科就诊。入院前1天首次出现皮损,先发生于大腿,继而蔓延至小腿及前臂。此外,那天早上病人醒来时枕头上有血。根据病历,在症状出现的前一天,患者接受了第一剂辉瑞(美国纽约州纽约市)- BioNTech(德国美因茨)BNT16B2b2 mRNA疫苗。入院时,体格检查发现口腔和鼻粘膜上有多个大小不一的出血​​性水疱(图 1a)。此外,可见位于小腿、大腿和前臂的紫癜性皮疹(图 1b)。在注射部位,观察到直径为 2 cm 的瘀斑(图 1c)。患者没有报告任何与粘液和皮肤损伤相关的主观症状。除高血压外,患者无其他慢性病。没有异常出血史或凝血病家族史。进行的实验室检查显示严重的血小板减少症(2*109 /L),具有正常的凝血参数。正常的d-二聚体浓度使我们能够排除相关的血栓形成。根据临床表现和实验室检查,诊断为与SARS-CoV-2疫苗相关的免疫性血小板减少性紫癜。患者被转移到血液科,据我们所知,他连续三天接受了 40 mg 地塞米松的快速推注。此外,还进行了血小板输注。

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图1
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黏膜出血性水疱(a),下肢紫疹(b)和患者手臂瘀斑(c)。

免疫性血小板减少症 (ITP) 是一种免疫介导的疾病,由血小板计数减少定义,通常没有白细胞减少和贫血的迹象,这可能是危及生命的出血的原因。1可能是特发性的;然而,它通常是由感染 Epstein-Barr、水痘-带状疱疹或流感病毒引起的。它也可能在接种疫苗后发生,尤其是麻疹-腮腺炎-风疹 (MMR)、甲型和乙型肝炎、白喉-破伤风-无细胞百日咳 (DTaP) 和水痘。2最近,描述了 COVID-19 ChAdOx1 疫苗接种后的大量 ITP 病例。3不良反应导致国际上对阿斯利康疫苗的质疑。已经提出了针对 COVID-19 疫苗诱导的血栓形成和血小板减少症 (VITT) 管理的具体指南。3, 4在其他 COVID-19 疫苗之后出现免疫性血小板减少性紫癜,除了一些新闻稿外,文献中很少报道。Lee等人最近的评论。5人在 BNT16B2b2 疫苗后将 9 名 ITP 患者分组。其中2例出现牙龈出血或颊大疱,部分出现瘀点,仅1例出现播散性紫癜。5只有一名患者早在接种疫苗后的第二天就出现了症状;然而,他们中的大多数人的血小板计数与我们的患者相似。还描述了一些与 COVID-19 mRNA 1273 (Moderna) 疫苗相关的免疫性血小板减少性紫癜患者,但没有血栓形成。6上述患者的 ITP 管理主要包括全身性皮质类固醇和血小板输注。据我们所知,这是皮肤病学文献中报道的首例免疫性血小板减少性紫癜。皮肤科医生应该意识到在 COVID-19 疫苗接种后发生 ITP 以及随后的黏液和皮肤损伤的可能性,不仅与 ChAdOx1 疫苗有关。进一步的观察将有助于确定特定 COVID-19 疫苗后发生免疫性血小板减少性紫癜的真正风险。

更新日期:2021-06-02
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