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Elsaid M, Nune A, Brakat AM, Anand A, Alashwah M, Maher A, Lama N, Peñamante CAC. Immune thrombocytopenic purpura after influenza vaccine administration; a systematic review and meta-analysis. Trop Dis Travel Med Vaccines 2023; 9:22. [PMID: 38001495 PMCID: PMC10675976 DOI: 10.1186/s40794-023-00206-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/07/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND The American Society of Haematology defines immune thrombocytopenic purpura (ITP) as a common hematologic disorder characterized by a transient or long-term decrease in platelet counts (< 100 × 109/L.), purpura, and haemorrhagic episodes caused by antiplatelet autoantibodies, with the exclusion of other clinical conditions. We aimed to systematically determine the incidence of ITP in adults and children following influenza vaccination, the duration between vaccination and the occurrence of ITP, and to identify predictors of ITP after the vaccine. METHODS We searched PubMed, Cochrane Library, Google Scholar, Web of Science, Scopus, and Science Direct. We included primary studies that assessed the occurrence of immune thrombocytopenia in individuals who had received any influenza vaccine (primary or booster dose), regardless of the dosage, preparation, time of administration, or age of the participants. We excluded studies that were (a) Narrative, scoping, and umbrella reviews ;(b) studies with no accessible full text, abstract-only studies, or (c) Overlapping or unreliable data. The risk of bias in the included studies was assessed using the Joanna Briggs Institute (JBI) tool. We categorized studies for qualitative analysis based on study design. Descriptive statistics were used to summarize quantitative data, including the incidence of ITP after influenza vaccination. RESULTS Out of 729 articles retrieved from the database search, we included 24 studies. All patients identified and included in this systematic review presented with immune thrombocytopenia, determined by their platelet count. The period between vaccination and the occurrence of ITP ranged from (2:35 days). The mean duration was 13.5 days. The analysis revealed a statistically significant incidence rate ratio (IRR) = 1.85,95% CI [1.03-3.32] of ITP occurrence after 42 days. CONCLUSIONS Influenza-associated ITP is uncommon, self-limiting, non-life-threatening, and curable. None of the patients reported having severe adverse events or death. Further studies are required to confirm the exact incidence of the ITP to better understand the pathophysiology of ITP development post-influenza vaccination.
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Affiliation(s)
- Mohamed Elsaid
- Faculty of Medicine, Misr University for Science and Technology, 6th of October, Giza, Egypt.
- Medical Research Platform, Giza, Egypt.
| | - Arvind Nune
- Department of Rheumatology and General Medicine, Southport and Ormskirk Hospital NHS Trust, Southport, UK
| | - Aml M Brakat
- Faculty of Medicine, Zagazig University, Ash Sharqia Governorate, Egypt
- Medical Research Platform, Giza, Egypt
| | - Ayush Anand
- B. P. Koirala Institute of Health Sciences, Dharan, Nepal
- Medical Research Platform, Giza, Egypt
| | - Mahmoud Alashwah
- Faculty of Medicine, Cairo University, Cairo, Egypt
- Medical Research Platform, Giza, Egypt
| | - Ahmed Maher
- Faculty of Medicine, Al-Azhar University, New-Damietta, Egypt
- Medical Research Platform, Giza, Egypt
| | - Nitu Lama
- Dr. M. V. Shetty College of Physiotherapy, Rajiv Gandhi University of Health Sciences, Mangaluru, India
- Medical Research Platform, Giza, Egypt
| | - Criselle Angeline C Peñamante
- Department of Clinical Epidemiology, Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
- Department of Psychology, College of Science, University of Santo Tomas, Manila, Philippines
- Medical Research Platform, Giza, Egypt
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Liu W, Wu T, Xue F, Tian H, Song R, Bai H. Immune thrombocytopenic purpura induced by the COVID‑19 vaccine after the second dose in a 78‑year‑old patient: A case report. Exp Ther Med 2022; 24:580. [PMID: 35949340 PMCID: PMC9353547 DOI: 10.3892/etm.2022.11517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/27/2022] [Indexed: 01/08/2023] Open
Affiliation(s)
- Wenhui Liu
- Department of Hematology, The 940th Hospital of Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
| | - Tao Wu
- Department of Hematology, The 940th Hospital of Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
| | - Feng Xue
- Department of Hematology, The 940th Hospital of Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
| | - Hongjuan Tian
- Department of Hematology, The 940th Hospital of Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
| | - Rui Song
- Department of Hematology, The 940th Hospital of Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
| | - Hai Bai
- Department of Hematology, The 940th Hospital of Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
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Küster O, Schmohl J, Greiner J, Storz MA. Severe immune thrombocytopenia following diphtheria, tetanus, pertussis and polio vaccination in a 36-year-old Caucasian woman: a case report. Eur J Med Res 2022; 27:63. [PMID: 35505368 PMCID: PMC9062629 DOI: 10.1186/s40001-022-00686-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 04/11/2022] [Indexed: 12/29/2022] Open
Abstract
Background Immune thrombocytopenia (ITP) is a rare autoimmune disorder characterized by low platelet counts and increased bleeding risk. The disease may be induced by other disorders, including malignancies, autoimmune diseases, infectious agents or drugs. However, ITP has also been described following vaccinations, such as the measles–mumps–rubella vaccination. In rare cases, ITP may occur in children who received a DTaP-IP (diphtheria, tetanus, acellular pertussis vaccine and inactivated poliovirus) vaccine. Hereinafter, we report the first well-documented cases of ITP in an adult patient in the temporal context of a DTaP-IP vaccination. Case presentation This case report attempts to capture the life-threatening picture of a 36-year-old otherwise healthy Caucasian woman with newly diagnosed severe immune thrombocytopenia in the temporal context of a DTaP-IP vaccination. Four days after receiving the vaccine, the women presented to her primary care physician with malaise, fever and recurrent epistaxis. Clinical examination revealed oral petechiae, ecchymoses, and non-palpable petechiae on both legs. The patient was immediately referred to a local hematology unit where she developed hematuria and an intestinal bleeding (WHO Bleeding Grade III) requiring multiple transfusions. After receiving oral corticosteroids and intravenous immunoglobulins, her platelets gradually recovered. Common causes of secondary ITP were ruled out by laboratory investigations, bone marrow and peripheral blood examinations. This raises the possibility of a (secondary) vaccination-associated thrombocytopenia. To the best of our knowledge, this is the first well-documented case of a DTaP-IP vaccination-related ITP in an adult patient in the English literature. Conclusion Although a causal connection between both entities may not be established, we would like to raise awareness in clinicians that ITP following DTaP-IP vaccinations is potentially not limited to children, but may also occur in adults. Users of DTaP-IP booster vaccines should be alert of the possibility of such adverse reactions. Supplementary Information The online version contains supplementary material available at 10.1186/s40001-022-00686-z.
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Affiliation(s)
- Onno Küster
- MVZ Dillmannstraße, Dillmannstraße 19, 70193, Stuttgart, Baden-Württemberg, Germany
| | - Jörg Schmohl
- Department of Internal Medicine, Diakonie Hospital Stuttgart, 70176, Stuttgart, Germany
| | - Jochen Greiner
- Department of Internal Medicine, Diakonie Hospital Stuttgart, 70176, Stuttgart, Germany
| | - Maximilian Andreas Storz
- Department of Internal Medicine II, Center for Complementary Medicine, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany.
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Immune Thrombocytopenia Induced by the Chimpanzee Adenovirus-Vectored Vaccine against SARS-CoV-2 Infection. Vaccines (Basel) 2021; 9:vaccines9121486. [PMID: 34960232 PMCID: PMC8707922 DOI: 10.3390/vaccines9121486] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/29/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022] Open
Abstract
We present a case of immune thrombocytopenia (ITP) induced by the chimpanzee adenovirus-vectored vaccine, without evidence of thrombosis, eight days after vaccine administration. The thrombocytopenia condition improved after administering steroid treatment. This adenovirus vaccine had been reported to induce rare side effects, such as immune thrombotic thrombocytopenia. This case report showed that it could also induce immune thrombocytopenia without the presence of thrombosis. Therefore, we should be cautious of this rare side effect as global vaccine administrations against coronavirus disease increase.
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Gronbeck C, Grant-Kels JM. Attention all anti-vaccinators: The cutaneous adverse events from the mRNA COVID-19 vaccines are not an excuse to avoid them! Clin Dermatol 2021; 39:674-687. [PMID: 34809772 PMCID: PMC8139532 DOI: 10.1016/j.clindermatol.2021.05.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite the growing availability of coronavirus disease 2019 (COVID-19) vaccines in the general population, a significant proportion of individuals demonstrate vaccine hesitancy. We sought to consolidate and update current evidence on cutaneous adverse events from COVID-19 vaccines to aid in the education and counseling of patients concerned about potential cutaneous side effects. We conducted a literature review of PubMed in May 2021 to identify reports of cutaneous events after vaccination with the Pfizer-BioNTech and Moderna vaccines (postauthorization clinical reports pertaining to the Johnson & Johnson and AstraZeneca vaccines were limited). Event reports in the Vaccine Adverse Event Reporting System were reviewed. Localized cutaneous reactions were common after the mRNA vaccines, consistent with clinical trial findings. Reported urticarial and morbilliform eruptions may reflect immediate hypersensitivity but have rarely been associated with anaphylaxis. There are infrequent reports of herpes zoster, dermatologic filler reactions, and immune thrombocytopenia, mainly occurring in high-risk patient groups. Ultimately, the identified cutaneous reactions are largely self-limited and should not discourage vaccination. Existing reports should reassure patients of the overall compelling safety profiles of the mRNA COVID-19 vaccines and benignity of skin reactions after vaccination.
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Affiliation(s)
- Christian Gronbeck
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA.
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Idogun PO, Ward MC, Teklie Y, Wiese-Rometsch W, Baker J. Newly Diagnosed Idiopathic Thrombocytopenia Post COVID-19 Vaccine Administration. Cureus 2021; 13:e14853. [PMID: 34113494 PMCID: PMC8176657 DOI: 10.7759/cureus.14853] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A few individuals are believed to have developed immune thrombocytopenia (ITP) following the administration of the coronavirus disease 2019 (COVID-19) vaccine. This phenomenon has been reported in a few case reports and also in some recent news articles. In this report, we discuss a case of a 54-year-old Caucasian female who presented to the emergency room with life-threatening thrombocytopenia in the setting of de novo ITP following COVID-19 vaccine administration. Due to the relapsing nature of ITP, it is unclear if the patient has achieved complete remission of the disease.
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Affiliation(s)
- Precious O Idogun
- Florida State University College of Medicine Internal Medicine Residency, Sarasota Memorial Hospital, Sarasota, USA
| | - Mindy C Ward
- Florida State University College of Medicine Internal Medicine Residency, Sarasota Memorial Hospital, Sarasota, USA
| | - Yeshanew Teklie
- Florida State University College of Medicine Internal Medicine Residency, Sarasota Memorial Hospital, Sarasota, USA
| | - Wilhelmine Wiese-Rometsch
- Florida State University College of Medicine Internal Medicine Residency, Sarasota Memorial Hospital, Sarasota, USA
| | - Joel Baker
- Florida State University College of Medicine Internal Medicine Residency, Sarasota Memorial Hospital, Sarasota, USA
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Helms JM, Ansteatt KT, Roberts JC, Kamatam S, Foong KS, Labayog JMS, Tarantino MD. Severe, Refractory Immune Thrombocytopenia Occurring After SARS-CoV-2 Vaccine. J Blood Med 2021; 12:221-224. [PMID: 33854395 PMCID: PMC8040692 DOI: 10.2147/jbm.s307047] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 03/15/2021] [Indexed: 12/13/2022] Open
Abstract
The rollout of the SARS-CoV-2 vaccine is underway, and millions have already been vaccinated. At least 25 reports of "immune thrombocytopenia" (ITP) or "thrombocytopenia" following the Moderna or Pfizer vaccine have been added to the Vaccine Adverse Event Reporting System (VAERS) in the US. ITP is a rare but known complication of several vaccinations. SARS-CoV-2 vaccine is new, with a novel mechanism of action, and understanding the epidemiology, clinical manifestations, treatment success and natural history of post-vaccination thrombocytopenia is evolving. 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. Possibly, but less likely given the temporality, the drug-induced thrombocytopenia was subsiding. The aggressive use of immunosuppressive treatment may jeopardize the intended purpose of the SARS-CoV-2 vaccine, and earlier use of non-immunosuppressive second-line treatment for vaccine-related severe thrombocytopenia, such as with TPO-RAs, should be considered. While it is imperative to continue the global vaccination program, vigilance to the occurrence of post-vaccination severe thrombocytopenia is warranted.
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Affiliation(s)
- Jackie M Helms
- The Bleeding and Clotting Disorders Institute, Peoria, IL, USA
| | | | - Jonathan C Roberts
- The Bleeding and Clotting Disorders Institute, Peoria, IL, USA
- Department of Medicine, University of Illinois College of Medicine-Peoria, Peoria, IL, USA
| | - Sravani Kamatam
- Department of Medicine, Saint Francis Medical Center, Peoria, IL, USA
| | - Kap Sum Foong
- Department of Medicine, University of Illinois College of Medicine-Peoria, Peoria, IL, USA
- Department of Medicine, Saint Francis Medical Center, Peoria, IL, USA
| | - Jo-mel S Labayog
- Department of Medicine, OSF Sacred Heart Medical Center, Danville, IL, USA
| | - Michael D Tarantino
- The Bleeding and Clotting Disorders Institute, Peoria, IL, USA
- Department of Medicine, University of Illinois College of Medicine-Peoria, Peoria, IL, USA
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Vigilance regarding immune thrombocytopenic purpura after COVID-19 vaccine. Ir J Med Sci 2021; 191:919-920. [PMID: 33788135 PMCID: PMC8011062 DOI: 10.1007/s11845-021-02614-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/28/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Based on the severity of thrombocytopenia, patients with immune thrombocytopenic purpura (ITP) are at an increased risk of mucocutaneous or major bleeding. DISCUSSION There has been an increased risk of ITP after administration of various vaccines like influenza, measles-mumps-rubella, hepatitis B, and diphtheria-tetanus-pertussis. The pathogenesis of vaccine-related thrombocytopenia is not completely clear and is probably caused by molecular mimicry. Till date, there have been few reported cases of thrombocytopenia in the pharmacovigilance databases after patients received the Pfizer and Moderna coronavirus disease-19 (COVID-19) vaccines. CONCLUSION Emergency physicians should be aware of the occurrence of vaccine-induced ITP in patients who present with bleeding manifestations, especially after the current boost in COVID-19 vaccination drive worldwide.
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Malayala SV, Mohan G, Vasireddy D, Atluri P. Purpuric Rash and Thrombocytopenia After the mRNA-1273 (Moderna) COVID-19 Vaccine. Cureus 2021; 13:e14099. [PMID: 33786251 PMCID: PMC7996471 DOI: 10.7759/cureus.14099] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The mRNA-1273 vaccine, popularly called the "Moderna vaccine" is being widely administered in the United States for the prevention of COVID-19 infection since December 2020. Mild to moderate intensity side effects like low-grade fever, myalgia, chills and malaise were reported in the trials related to the vaccine. With this case report, we report a case of purpuric rash and thrombocytopenia after receiving the first dose of the m-RNA-1273 vaccine. The patient, in this case, is a 60-year-old male patient who received the first vaccine dose and within two days, he developed diffuse papular rash associated with some thrombocytopenia. He had a history of tobacco use, Hepatitis C liver cirrhosis, chronic kidney disease stage 4, untreated hypertension and systolic congestive heart failure at the baseline. With review of the limited literature related to the vaccine and its side effect profile and with no other etiology explaining the sudden onset of rash, we attribute this thrombocytopenia and purpuric rash as the side effects of the mRNA-1273 vaccine.
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Affiliation(s)
| | - Gisha Mohan
- Medical Research, Physicians of American Healthcare Access, Philadelphia, USA
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Yamamoto Y, Ohara Y, Iwai A, Hara R, Matsuki T, Fukushima K, Oshitani Y, Kagawa H, Tsujino K, Yoshimura K, Miki M, Miki K, Mori M, Kida H. Influenza Vaccination-associated Acute Thrombocytopenia and Diffuse Alveolar Hemorrhage. Intern Med 2020; 59:1633-1637. [PMID: 32188805 PMCID: PMC7402960 DOI: 10.2169/internalmedicine.3991-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Influenza vaccination can trigger various adverse reactions, and thrombocytopenia is also rarely reported. Although patients with mild thrombocytopenia are sometimes asymptomatic, severe thrombocytopenia can cause severe bleeding. We herein report a rare case of severe thrombocytopenia that occurred within one day of influenza vaccination and diffuse alveolar hemorrhage (DAH) leading to acute respiratory failure. The patient was treated with glucocorticoid pulse therapy, intravenous immunoglobulin, and temporary mechanical ventilation, and eventually he made a full recovery. Vaccine-related thrombocytopenia and DAH should be considered adverse reactions, even if they develop very soon after vaccination.
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Affiliation(s)
- Yuji Yamamoto
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Yuko Ohara
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
- Department of Respiratory Medicine, Yodogawa Christian Hospital, Japan
| | - Ami Iwai
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Reina Hara
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Takanori Matsuki
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Kiyoharu Fukushima
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Yohei Oshitani
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Hiroyuki Kagawa
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Kazuyuki Tsujino
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Kenji Yoshimura
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Mari Miki
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Keisuke Miki
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Masahide Mori
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
| | - Hiroshi Kida
- Department of Respiratory Medicine, National Hospital Organization Osaka Toneyama Medical Center, Japan
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Almohammadi A, Lundin MS, Abro C, Hrinczenko B. Epistaxis and gross haematuria with severe thrombocytopaenia associated with influenza vaccination. BMJ Case Rep 2019; 12:12/5/e229423. [PMID: 31061198 DOI: 10.1136/bcr-2019-229423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Epistaxis may be attributed to many causes during the winter including dry mucous membranes from low indoor humidity from heating. However, epistaxis may also be due to thrombocytopaenia. Immune thrombocytopaenia purpura (ITP) is an autoimmune disorder causing thrombocytopaenia. Viral infections sometimes lead to ITP. Vaccines, predominantly the measles-mumps-rubella vaccine, have been associated with the development of ITP. There are several published case reports regarding influenza vaccine induced ITP. However, an association between ITP and influenza vaccination has not been firmly proven yet. We report the case of an adult with three episodes of epistaxis, each within 1 week of receiving a yearly influenza trivalent inactivated vaccine, the last episode being more severe and also featuring gross haematuria.
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Affiliation(s)
- Abdullah Almohammadi
- Hematology and Oncology, Michigan State University, Lansing, Michigan, USA.,Internal Medicine, Sparrow Hospital, Lansing, Michigan, USA
| | - Michael S Lundin
- Internal Medicine, Sparrow Hospital, Lansing, Michigan, USA.,Internal Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Calvin Abro
- Internal Medicine, Sparrow Hospital, Lansing, Michigan, USA.,Internal Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Borys Hrinczenko
- Hematology and Oncology, Michigan State University, Lansing, Michigan, USA.,Internal Medicine, Sparrow Hospital, Lansing, Michigan, USA
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Affiliation(s)
- Firdos Ahmad
- Sharjah Institute for Medical Research and College of Medicine, University of Sharjah, United Arab Emirates
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