1 Grady D.

Mazzei P. Death of a doctor who got Covid shot is being investigated. Recently, it was reported that a physician developed petechiae 3 days after receiving the Pfizer-BioNTech Covid-19 vaccine, was diagnosed with idiopathic thrombocytopenic purpura, and ultimately died of a cerebral hemorrhage.Here, we report a case of idiopathic thrombocytopenic purpura in a 72-year-old woman 1 day after receiving the first dose of the Moderna COVID-19 vaccine.

The day after receiving her vaccination, the patient woke up with a rash, spontaneous oral bleeding, and headache. She denied any history of easy bruising or abnormal bleeding. Her medical history included gout, type 2 diabetes mellitus, and seasonal contact dermatitis. She denied any new medications or changes to her allopurinol and sitagliptin within the last 5 years. She denied any family history of autoimmune disorders.

Table 1 Clinical laboratory results. Measure Reference Range Hospital Day 1 Hospital Day 3 Hospital Day 5 Hospital Day 8 Hemoglobin (g/dL) 12.0–16.0 13.3 12.2 10.8 ∗ The value in this patient was below normal. 11.1 ∗ The value in this patient was below normal. Hematocrit (%) 37.0–47.0 41.2 36.3 ∗ The value in this patient was below normal. 33.9 ∗ The value in this patient was below normal. 34.5 ∗ The value in this patient was below normal. Platelet count (per μL) 150,000–400,000 12,000 ∗ The value in this patient was below normal. 9,000 ∗ The value in this patient was below normal. 11,000 ∗ The value in this patient was below normal. 1,000 ∗ The value in this patient was below normal. White-cell count (per μL) 4,800–10,800 5,320 5,360 3,020 ∗ The value in this patient was below normal. 3,300 ∗ The value in this patient was below normal. Mean corpuscular volume (fL) 80.0–99.0 92.6 90.5 92.6 92.5 Mean corpuscular hemoglobin (pg) 27.0–31.0 29.9 30.4 29.5 29.8 Mean corpuscular hemoglobin concentration (g/dL) 29.8–35.2 32.3 33.6 31.9 32.2 Red-cell distribution width (%) 12.0–15.0 12.3 12.3 12.0 12.0 Differential count (per μL) Neutrophils 2,100–7,600 3,510 3,630 1600 ∗ The value in this patient was below normal. 2,350 Lymphocytes 1,000–4,900 1,260 1,160 980 ∗ The value in this patient was below normal. 580 ∗ The value in this patient was below normal. Monocytes 100–1,100 410 480 350 290 Eosinophils 100–400 110 60∗ 50 ∗ The value in this patient was below normal. 80 ∗ The value in this patient was below normal. Basophils 0–200 2 1 2 1 Sodium (mmol/L) 136–145 140 141 138 137 Potassium (mmol/L) 3.5–5.1 3.7 4.1 3.9 3.8 Chloride (mmol/L) 98–108 100 104 104 101 Carbon dioxide (mmol/L) 22–29 26 25 28 28 Urea nitrogen (mg/dL) 6.0–23.0 14 19 21 16 Creatinine (mg/dL) 0.50–1.20 0.76 0.68 0.73 0.76 Glucose (mg/dL) 74–110 103 105 102 112 ∗ The value in this patient was below normal. Calcium (mg/dL) 8.6–10.3 9.3 9.1 8.9 9 Total protein (g/dL) 6.6–8.7 7.2 6.4 ∗ The value in this patient was below normal. — 8.2 Albumin (g/dL) 3.5–5.2 4.6 4.0 — 3.7 Aspartate aminotransferase (U/L) 5–32 21 16 — 18 Alanine aminotransferase (U/L) 0–33 13 10 — 12 Alkaline phosphatase (U/L) 35–104 98 82 — 73 Total bilirubin (mg/dL) 0.0–1.2 2.8 † The value in this patient was above normal. 2.1 † The value in this patient was above normal. — 1.9 † The value in this patient was above normal. Direct bilirubin (mg/dL) 0.0–0.3 0.4 0.3 — 0.3 Magnesium (mg/dL) 1.6–2.6 2.1 2.1 — 2.1 Phosphorus (mg/dL) 2.5–4.5 3.4 2.6 3.9 2.8 Prothrombin time (seconds) 10.0–13.0 11.8 — — — International normalized ratio 1 — — — Activated partial-thromboplastin time (seconds) 25.1–36.5 31.7 — — — Fibrinogen (mg/dL) 200–393 359 — — — D-dimer (ng/mL DDU) 0–243 216 — — — Iron (ng/μL) 37–145 45 — — — Unsaturated iron-binding capacity (ng/μL) 112.0–347.0 275.5 — — — Total iron-binding capacity (ng/μL) 220–430 320 — — — Haptoglobin (mg/dL) 34–200 106 — — — Central venous oxygen saturation (%) 60.0–85.0 78.9 — — — Ionized calcium (mmol/L) 1.16–1.32 1.22 — — — Lactic acid (mmol/L) 0.6–1.4 1.5† — — — Thyroid stimulating hormone (mlU/L) 0.27–4.20 1.29 — — — Vitamin B12 (pg/mL) 211–946 299 — — — SARS-CoV-2 RNA NA Not detected — — — SARS-CoV-2 antibody index <0.99 0.08 — — — Influenza A RNA NA Not detected — — — Influenza B RNA NA Not detected — — — Hepatitis A IgM antibodies NA Non-reactive — — — Hepatitis B surface antibody NA Reactive — — — Hepatitis B surface antigen NA Non-reactive — — — Hepatitis B core IgM antibody NA Non-reactive — — — Hepatitis C RNA NA Not detected — — — HIV 1,2 antigen and antibody assay NA Non-reactive — — — Cytomegalovirus PCR NA Not detected — — — Epstein-Barr virus PCR NA Not detected — — — Parvovirus B19 IgM antibodies NA Negative — — — Parvovirus B19 IgG antibodies NA Positive — — — H. pylori stool antigen NA Not detected — — — Antinuclear antibody NA Negative — — — NA, not applicable; PCR, polymerase chain reaction. On examination, she had diffuse petechiae across her arms, legs, and abdomen and hemorrhagic bullae of the gingival mucosa. Laboratory tests were notable for an initial platelet count of 12,000/μL, decreasing to 1,000/μL within 12 hours of arrival. Other laboratory tests are as shown in Table 1 . Of note, normal prothrombin time, activated partial-thromboplastin time, d-dimer, and fibrinogen ruled out disseminated intravascular coagulation. Further, normal hemoglobin, haptoglobin, lactate dehydrogenase, and peripheral smear without schistocytes were inconsistent with hemolytic uremic syndrome or thrombotic thrombocytopenic purpura. Viral studies, including hepatitis A, B, and C, Epstein-Barr virus, HIV, cytomegalovirus, influenza A and B, and SARS-CoV-2, revealed no evidence of current or prior infection. Parvovirus IgG but not IgM antibodies were present, indicating prior resolved infection. Antinuclear antibody titers were undetectable, making rheumatic etiology less likely.

The patient received an initial 40-mg intravenous dose of dexamethasone and additional doses of 20 mg/day for 3 days thereafter. Intravenous immunoglobulin, aminocaproic acid, and rituximab were administered, and she received multiple platelet transfusions. However, her platelets continued to fluctuate between 1,000/μL and 40,000/μL. Non-contrast computed tomography of the head was without evidence of intracranial bleeding. Her course was complicated by multiple episodes of melena.

2 Cecinati V.

Principi N.

Brescia L.

et al. Vaccine administration and the development of immune thrombocytopenic purpura in children. 3 David P.

Shoenfeld Y. ITP following vaccination. 4 Castells M.C.

Phillips E.J. Maintaining safety with SARS-CoV-2 vaccines. Idiopathic thrombocytopenic purpura postvaccination has been reported in the measles, mumps, and rubella vaccineand has been associated with the use of attenuated vaccines and vaccine adjuvants, with one review identifying 45% of drug-induced idiopathic thrombocytopenic purpura occurring postvaccination.While hypersensitivity reactions are a known adverse event related to mRNA COVID-19 vaccines,this is, to our knowledge, the second known case of acute idiopathic thrombocytopenic purpura following administration.

Acknowledgments Drs. Julian and Mathern are co-first authors and have contributed equally to this article.

Article Info Publication History Footnotes Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Identification DOI: https://doi.org/10.1016/j.annemergmed.2021.02.011 Copyright © 2021 by the Elsevier Ltd. ScienceDirect Access this article on ScienceDirect

Related Articles

To the Editor: