Immune thrombocytopenic purpura secondary to COVID-19 vaccination: A systematic review

Risk factors and disease trajectories of recurrent immune thrombocytopenia in children

This retrospective study aimed to analyse the course and outcome of recurrent immune thrombocytopenia (ITP) in children and to identify factors associated with recurrence. A total of 497 newly diagnosed ITP children with platelet <30 × 109/L between January 1988 and December 2019 were included. Recurrent ITP was defined as a new event of thrombocytopenia after at least 3 months of remission without treatment. Twenty-nine (5.8%) children experienced 48 recurrent episodes. The median time from diagnosis to recurrence was 22 months. Most recurrences occurred in children aged 1.5-10 years with a recent infection history. Compared to non-recurrent ITP, children with recurrent ITP had delayed remission with lower platelets at 1 month and 3 months postdiagnosis. Multivariate analysis identified aged 1.5-10 years (hazard ratio [HR] 3.65, 95% confidence interval [CI]: 1.35-9.82) and delayed remission at 7-12 months (HR 4.04, 95% CI: 1.37-11.95) as predictors for recurrence. Most recurrent ITP patients had minor or mild symptoms, higher platelet counts, did not require treatment, and achieved remission within 12 months. The similar remission trajectories among the first and recurrent ITP, but different from the courses in the non-recurrent ITP, suggest that recurrent ITP might have a unique biological basis.

The WHO Algorithm for Causality Assessment of Adverse Effects Following Immunization with Genetic-Based Anti-COVID-19 Vaccines: Pitfalls and Suggestions for Improvement

Clarifying and differentiating the causes of diseases is an essential step in any clinical activity, but it takes on particular relevance and complexity in the case that arise following vaccinations. The WHO has proposed a protocol that uses a list of specific questions about vaccine-related adverse events and an algorithm for making a judgement. Here, we analyze and discuss the important limitations of this protocol when applied to the new genetic-based anti-COVID-19 vaccines, particularly once dealing with rare and unexpected pathological events. The main controversial aspects concern: (a) the prevailing consideration of other possible causes; (b) the biological plausibility and the choice of an appropriate time window to consider adverse effects possibly caused by vaccines; (c) the reference to scientific literature, which may be very limited and often controversial in early stages of introducing new vaccines because of the short period of observation; (d) the final classification of the algorithm into only three classes, which leaves ample space for the "indeterminate" category. Failure to address these issues may lead to distorted pharmacovigilance reports with significant consequences on the benefit/harm assessment. In anticipation of possible future pandemics managed with new vaccines, the WHO algorithm needs to be revised with appropriate protocols for monitoring and evaluation of adverse effects that take into account the novel mechanism of action and real-world epidemiological data.

COVID-19-Vaccination-Induced Localized Lichen Planus Successfully Treated With Phototherapy

Lichen planus (LP) is an inflammatory autoimmune mucocutaneous disease with different forms and presentations. It mainly affects the skin and oral mucosa but could also affect genital mucosa, nails, hair, and, rarely, the larynx and esophagus. Since the start of the COVID-19 era, multiple cutaneous manifestations related to SARS-CoV-2 infection or vaccination have been reported. Different rare cases of lichen planus were reported after COVID-19 infection and vaccination. This report elaborates on and adds an additional case of localized cutaneous lichen planus (CLP) to the upper extremities, which developed after both doses of the mRNA vaccine and improved after phototherapy.

SARS-CoV-2 PCR cycle threshold value at admission might not be a good predictor of in-hospital COVID-19-associated AKI

Background

Acute kidney injury (AKI) is a prevalent complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and a predictor of disease severity and mortality; furthermore, a prompt diagnosis and treatment of this complication may enhance COVID-19 prognosis. Therefore, we aim to investigate potential risk factors for SARS-CoV-2-associated AKI, including SARS-CoV-2 PCR cycle threshold value (CT value), which correlation with AKI is conflicting.

Methods

This case-control study included 110 hospitalized patients with SARS-CoV-2-associated AKI as cases and 110 random SARS-CoV-2 hospitalized patients as controls. Reverse transcription real-time PCR of admission nasopharyngeal swabs evaluated E gene cycle thresholds. Additional clinical and paraclinical information extracted from medical records. The patient's status at discharge, and 14 and 30 days after discharge. Therefore, after adjusting for age and gender, the correlation between variables was assessed.

Results

SARS-CoV-2 AKI is significantly associated with age above 60, hypertension, diabetes mellitus, ischemic heart disease, and underlying kidney diseases. Abnormal admission hemoglobin or alkaline phosphatase, proteinuria or hematuria in urine sediment, and abnormal creatinine during hospitalization were the paraclinical features correlated to SARS-CoV-2 AKI. AKI group demonstrated greater in-hospital, 14- and 30-day mortality. Nevertheless, this study did not evidence a correlation between the admission CT value and mortality or AKI.

Conclusion

Admission CT values provide limited information regarding the dynamic viral load and varying hospitalization time points; thus, they may not be reliable for predicting the prognosis and complications of COVID-19 in all populations. Further studies with serial CT measurements or symptom onset time adjustment are recommended.

Characteristics and outcomes of COVID-19 in Chinese immune thrombocytopenia patients: A prospective cohort study

The coronavirus disease 2019 (COVID-19) pandemic has a significant impact on the immune system. This is the first and largest study on pre-existing immune thrombocytopenia (ITP) patients infected with COVID-19 in China. We prospectively collected ITP patients infected with COVID-19 enrolled in the National Longitudinal Cohort of Hematological Diseases (NICHE, NCT04645199) and followed up for at least 1 month after infection. One thousand and one hundred forty-eight pre-existing ITP patients were included. Two hundred and twelve (18.5%) patients showed a decrease in the platelet (PLT) count after infection. Forty-seven (4.1%) patients were diagnosed with pneumonia. Risk factors for a decrease in the PLT count included baseline PLT count <50 × 109/L (OR, 1.76; 95% CI, 1.25-2.46; p = 0.001), maintenance therapy including thrombopoietin receptor agonists (TPO-RAs) (OR, 2.27; 95% CI, 1.60-3.21; p < 0.001) and previous splenectomy (OR, 1.98; 95% CI, 1.09-3.61; p = 0.03). Risk factors for pneumonia included age ≥40 years (OR, 2.45; 95% CI, 1.12-5.33; p = 0.02), ≥2 comorbidities (OR, 3.47; 95% CI, 1.63-7.64; p = 0.001), maintenance therapy including TPO-RAs (OR, 2.14; 95% CI, 1.17-3.91; p = 0.01) and immunosuppressants (OR, 3.05; 95% CI, 1.17-7.91; p = 0.02). In this cohort study, we described the characteristics of pre-existing ITP patients infected with COVID-19 and identified several factors associated with poor outcomes.

COVID-19 vaccination and the risk of autoimmune diseases: a Mendelian randomization study

Background

In recent times, reports have emerged suggesting that a variety of autoimmune disorders may arise after the coronavirus disease 2019 (COVID-19) vaccination. However, causality and underlying mechanisms remain unclear.

Methods

We collected summary statistics of COVID-19 vaccination and 31 autoimmune diseases from genome-wide association studies (GWAS) as exposure and outcome, respectively. Random-effects inverse variance weighting (IVW), MR Egger, weighted median, simple mode, and weighted mode were used as analytical methods through Mendelian randomization (MR), and heterogeneity and sensitivity analysis were performed.

Results

We selected 72 instrumental variables for exposure (p < 5 × 10-6; r2 < 0.001, genetic distance = 10,000 kb), and MR analyses showed that COVID-19 vaccination was causally associated with an increased risk of multiple sclerosis (MS) (IVW, OR: 1.53, 95% CI: 1.065-2.197, p = 0.026) and ulcerative colitis (UC) (IVW, OR: 1.00, 95% CI: 1.000-1.003, p = 0.039). If exposure was refined (p < 5 × 10-8; r2 < 0.001, genetic distance = 10,000 kb), the associations became negative. No causality was found for the remaining outcomes. These results were robust to sensitivity and heterogeneity analyses.

Conclusion

Our study provided potential evidence for the impact of COVID-19 vaccination on the risk of MS and UC occurrence, but it lacks sufficient robustness, which could provide a new idea for public health policy.

Thrombosis with thrombocytopenia syndrome (TTS) and vaccine-induced immune thrombocytopenia and thrombosis (VITT): Brighton Collaboration case definitions and guidelines for data collection, analysis, and presentation of immunisation safety data

This is a revision of the online November 2021 Brighton thrombosis with thrombocytopenia syndrome (TTS) case definition and a new Brighton Collaboration case definition for vaccine-induced immune thrombocytopenia and thrombosis (VITT). These case definitions are intended for use in clinical trials and post-licensure pharmacovigilance activities to facilitate safety data comparability across multiple settings. They are not intended to guide clinical management. The case definitions were developed by a group of subject matter and Brighton Collaboration process experts as part of the Coalition for Epidemic Preparedness Innovations (CEPI)-funded Safety Platform for Evaluation of vACcines (SPEAC). The case definitions, each with defined levels of diagnostic certainty, are based on relevant published evidence and expert consensus and are accompanied by specific guidelines for TTS and VITT data collection and analysis. The document underwent peer review by a reference group of vaccine safety stakeholders and haematology experts to ensure case definition useability, applicability and scientific integrity.

Immune Thrombocytopenia After COVID-19 Vaccine Requiring Splenectomy: A Case Report and Review of the Literature

Post-vaccination immune thrombocytopenia (ITP) is a rare but recognized adverse event believed to result from an autoimmune reaction triggered by the vaccine. This case report presents the fourth documented instance of severe ITP requiring splenectomy following the administration of a COVID-19 vaccine. The patient, a 54-year-old previously healthy female with no familial history of autoimmune or hematological disorders, developed ITP two weeks after the first dose of the COVID-19 vaccine. While most ITP cases associated with COVID-19 vaccines manifested after the second dose, this unique case demonstrated symptoms following the initial vaccination. Initially responsive to first-line management, the patient experienced a relapse upon receiving the second dose from a different vaccine manufacturer. Despite exhaustive medical interventions, the refractory nature of the condition persisted, ultimately mandating splenectomy for the achievement of complete remission. This case underscores the potential for serious, refractory ITP with the second dose of a COVID-19 vaccine, particularly in patients who initially developed ITP after the first dose, even if they had seemingly achieved complete remission. These findings emphasize the importance of vigilant monitoring and individualized treatment strategies in such cases, contributing valuable insights to the growing body of knowledge surrounding vaccine-induced ITP.

Interesting Mucocutaneous Manifestations in COVID-19 Infection or Vaccination Confirmed by Histopathology: A Case Series

Introduction

Mucocutaneous complications or adverse events due to SARS-CoV-2 infection or vaccination have been well delineated in the literature, respectively. Most eruptions are considered mild and self-limiting; however, for the atypical cases with a tentative clinical diagnosis, performing a biopsy and histopathological assessment is pivotal to confirm the diagnosis and subsequently prescribe a more tailored treatment. Despite the diverse reporting of such incidents globally, most studies restrict the rate of biopsied cases to less than 15%.

Case Presentations

This case series elucidates 20 patients referred to the tertiary dermatology clinic, including 14 COVID-19 infection-related eruptions such as lichen planus (LP), cutaneous vasculitis, pityriasis rosea (PR), discoid lupus erythematosus, guttate psoriasis, sarcoidosis, Raynaud's phenomenon, non-specific lesions resembling genital warts, Beau's line, and one severe case of purpura fulminans with a promising outcome. Moreover, we presented six vaccine-induced cases comprising LP, urticarial vasculitis, PR, parapsoriasis, and localized morphea. The diagnosis of all challenging cases has been proven by histopathological evaluation. We included pertaining anamnesis details of each patient and vivid classifying images to pinpoint the morphologic features of each condition.

Discussion

In line with our previous studies, the vaccine-induced eruptions were less severe compared to infection-related complications of COVID-19 and are mostly controllable by antihistamines and corticosteroid administration. Therefore, reporting such events should not impede COVID-19 vaccination in the general population.

Development of a Scoring Method Based on a Chest CT Scan to Determine the Outcomes of COVID-19 Patients

Introduction As COVID-19 shifts from pandemic urgency to endemic management, healthcare systems are faced with the evolving challenge of providing optimized care and adept resource allocation in this evolving landscape of the disease. However, the timely management and accurate assessment of disease severity remains a cornerstone of effective treatment. This study presents a pioneering scoring system, based on the primary chest CT scan findings, to predict patient outcomes and to equip clinicians with a tool that can expedite decision-making. Method A retrospective cohort study was conducted involving 406 confirmed COVID-19 cases referred to two of our hospitals in Tehran, between February and April 2020. Radiographic and CT scan data were sourced from the imaging archive system and evaluated by a certified radiologist. We devised distinct severity scores for CT findings, demographic factors, and clinical indicators. These were synthesized into a comprehensive severity score to forecast critical patient outcomes, such as mortality, ICU admission, intubation, or extended hospitalization. Of the total cases, 161 (39.7%) were classified as severe, while 245 (60%) fell into the low or moderate severity category. Results The mean score of demographic, CT scan, and clinical characteristics was significantly higher for those in the severe COVID-19 than the non-severe group. The cutoff score for predicting the outcomes in COVID-19 patients for demographic, clinical, and chest CT scan factors was 2.5, 9.5, and 8.5, respectively. Multivariate analysis indicated that each unit increase in these scores elevated the odds of fatal outcomes by 24%, 2.8%, and 12%, respectively. Then, using the comprehensive severity score, which is the sum of the above scores, we further predicted the disease severity. Conclusion The findings suggest that our innovative scoring system, based on initial chest CT scan findings, serves as a robust predictor of COVID-19 outcomes.

Relapse of immune thrombocytopenia after receiving AstraZeneca coronavirus disease-2019 vaccine: A case report

Immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by a low platelets count. In this paper, we present a case of ITP relapse in a 31-year-old Iranian woman as a potential complication of the AstraZeneca vaccine.

Comparative Analysis of De Novo Immune Thrombocytopenia Following mRNA COVID-19 Vaccine Versus Non-mRNA Vaccines and COVID-19: A Global Database Analysis

Introduction Autoimmune diseases have been linked to COVID-19 vaccines. An increasing number of cases have reported de novo immune thrombocytopenia (ITP) following mRNA COVID-19 vaccines. This study aims to investigate the incidence of de novo ITP following the mRNA COVID-19 vaccine in comparison to other non-mRNA vaccines and COVID-19. Methods Data were collected from the TriNetX global health research network, which covers over 117 million patients. Four different patient cohorts were included: those who received the mRNA COVID-19 vaccine (between 12/15/2020 - 5/1/2023), the influenza vaccine (between 01/01/2010 - 01/01/2020), tetanus, diphtheria, and pertussis/tetanus and diphtheria (Tdap/Td) vaccines (between 01/01/2010 - 01/01/2020), and those who had COVID-19 (between 01/01/2020 - 05/01/2023). A comparative analysis was conducted to examine the occurrence of de novo ITP within three weeks after receiving mRNA COVID-19 vaccine, non-mRNA vaccines, or upon diagnosis of COVID-19. Additionally, a comparative analysis was performed after 1:1 propensity score matching to balance baseline characteristics (age, sex, and race). Results The overall event rate was 0.07 per 10,000 for the mRNA COVID-19 vaccine, 0.25 per 10,000 for the influenza vaccine, and 0.28 per 10,000 for the Tdap/Td vaccines. Additionally, the incidence of de novo ITP following COVID-19 was 0.30 per 10,000. Those who received the influenza vaccine and Tdap/Td vaccines had higher rates of de novo ITP compared to the mRNA COVID-19 vaccine group, with a relative risk of 3.48 and 3.88, respectively. The occurrence of de novo ITP following COVID-19 was significantly higher compared to that following the mRNA COVID-19 vaccine, with a relative risk of 4.27. Post-propensity score matching analysis produced similar outcomes. Conclusions The findings of this study suggest that the incidence of de novo ITP is significantly lower following mRNA-based COVID-19 vaccines compared to non-mRNA vaccines and COVID-19.

Thrombotic thrombocytopenic purpura following ChAdOx1 nCov-19 vaccination: A case report

Vaccine-associated thrombotic thrombocytopenic purpura (TTP) is a rare type of acquired TTP recently reported after COVID-19 vaccination. Merely four cases are ascribed to the ChAdOx1 nCoV-19 vaccine in the medical literature till the preparation of this study. In this case report, we describe a 43-year-old man who developed symptoms of TTP four days after receiving the second dose of the ChAdOx1 nCoV-19 vaccine. Peripheral blood smear demonstrated multiple schistocytes. Given a high plasmic score, he received plasma exchange, corticosteroids, and rituximab, and later, low ADAMTS 13 activity and high-titer ADAMTS inhibition antibody confirmed the diagnosis of COVID-19 vaccine-associated TTP. COVID-19 vaccine-associated TTP is an infrequent consequence of SARS-CoV-2 vaccination but with a substantial mortality rate which must be considered as one of the crucial differential diagnoses of post-COVID-19 vaccine thrombocytopenia besides vaccine-induced immune thrombotic thrombocytopenia and Immune thrombocytopenic purpura.

Molecular Mimicry of the Viral Spike in the SARS-CoV-2 Vaccine Possibly Triggers Transient Dysregulation of ACE2, Leading to Vascular and Coagulation Dysfunction Similar to SARS-CoV-2 Infection

The benefits of SARS-CoV-2 spike mRNA vaccines are well known, including a significant decline in COVID-19 morbidity and a decrease in the mortality rate of SARS-CoV-2 infected persons. However, pharmacovigilance studies have revealed the existence of rare cases of cardiovascular complications after mass vaccination using such formulations. Cases of high blood pressure have also been reported but were rarely documented under perfectly controlled medical supervision. The press release of these warning signals triggered a huge debate over COVID-19 vaccines' safety. Thereby, our attention was quickly focused on issues involving the risk of myocarditis, acute coronary syndrome, hypertension and thrombosis. Rare cases of undesirable post-vaccine pathophysiological phenomena should question us, especially when they occur in young subjects. They are more likely to occur with inappropriate use of mRNA vaccine (e.g., at the time when the immune response is already very active during a low-noise infection in the process of healing), leading to angiotensin II (Ang II) induced inflammation triggering tissue damage. Such harmful effects observed after the COVID-19 vaccine evoke a possible molecular mimicry of the viral spike transiently dysregulating angiotensin converting enzyme 2 (ACE2) function. Although the benefit/risk ratio of SARS-CoV-2 spike mRNA vaccine is very favorable, it seems reasonable to suggest medical surveillance to patients with a history of cardiovascular diseases who receive the COVID-19 vaccine.