Case #1
A 53-year-old man with past medical history of Crohn’s disease well-controlled with Ustekinumab, and no prior history of thrombocytopenia or exposure to heparin was seen in Emergency Department at St. Michael Medical Center Silverdale, Washington (ED) with symptoms of intermittent episodes of high-grade fever with chills, diffuse myalgia and petechial rash over chest, abdomen and extremities that had started 2 days prior. He did not have symptoms of coryza, cough, headache, abdominal pain, rectal bleeding, dysuria, diarrhea or altered sensorium. He had received the second of the two doses of Pfizer-BioNTech COVID-19 vaccine 8 days prior to the onset of symptoms. In the ED, he had a temperature of 39 °C. He had petechiae in the oropharynx, anterior trunk and bilateral upper and lower extremities. Rest of the physical exam was unremarkable. A complete blood count (CBC) showed a platelet count of 2 × 109/L. Rest of the blood counts and red cell indices were normal. Peripheral blood film did not show platelet clumping or schistocytes. Current list of medications didn’t reveal any culprit medications and he had normal platelet count (254 × 109/L) 5 weeks prior. Urinalysis, Blood cultures and X-ray chest did not show any evidence of infectious etiology and he remained afebrile throughout hospital course. Viral respiratory panel including influenza A and B, RSV and COVID-19 was negative. Hepatitis C and HIV serology was non-reactive. Coagulation profile was normal. Computed tomography (CT) of the head, chest, abdomen and pelvis did not show any evidence of thrombosis. Spleen measured 14.2 cm. Complement levels and autoimmune panel including anti double stranded DNA antibody and anti CCP antibody was normal. Bone marrow biopsy showed normocellular bone marrow with mildly increased megakaryopoiesis, preserved trilineage hematopoiesis without atypia or increased blasts. Flow cytometry didn’t show any abnormal B cells without an increase in CD 34 positive blasts. He received intravenous immunoglobulin (IVIG) 1 g/kg/day for 2 consecutive days and oral dexamethasone 40 mg/day for 4 consecutive days. With this regimen, the platelet count normalized in about 4 days after initiation of therapy and the response was durable. (Fig. 1).
Case #2
A 67-year-old man with past medical history of seizure disorder, atrial fibrillation, chronic ITP in remission and no prior exposure to heparin, was seen in ED with symptoms of generalized weakness and melena. Patient reported that he had received the first dose of Pfizer-BioNTech COVID-19 vaccine two days prior to admission. Patient denied any recent flares of ITP and he had normal platelet counts in the range of 140–160 × 109/L since undergoing splenectomy 4 years ago. Physical exam showed generalized petechiae. Rectal exam revealed black tarry stools. Rest of the physical exam was unremarkable. A CBC showed a platelet count of 2 × 109/L. Rest of the blood counts and red cell indices were normal. Peripheral blood film did not show platelet clumping or schistocytes. Hepatitis C and HIV serology was non-reactive. Viral respiratory panel including influenza A and B, RSV and COVID-19 was negative. Coagulation profile was normal. Patient received two units of single-donor platelet transfusion without any significant improvement in platelet count, however melena stopped. CT of the head and chest were unremarkable while the CT of the abdomen showed mild rectal wall thickening with fat stranding suspicious of proctitis. The patient received IVIG 1 g/kg/day for 2 consecutive days and oral dexamethasone 40 mg/day for 4 consecutive days. He had a gradual improvement in platelet count which eventually normalized in about a week after initiation of therapy. (Figure 2) Patient was advised to defer the second dose of COVID-19 vaccine due to the occurrence of severe thrombocytopenia.
Case #3
A 59-year-old woman with past medical history of chronic ITP and systemic lupus erythematosus (SLE) on hydroxychloroquine was seen in ED for symptoms of abdominal cramps and diarrhea that started 2 days after she had received Johnson and Johnson Covid-19 vaccine. Patient’s previous flare of ITP was two years ago which was precipitated by Shingrex vaccine that was treated successfully with steroids, following which her platelet count remained stable (~ 100 × 109/L). Physical exam was unremarkable. A complete blood test showed a platelet count of 64 × 109/L and subsequently dropping to 27 × 109/L the following day. Peripheral blood film did not show platelet clumping or schistocytes. CT abdomen showed mild distal colitis. Prior laboratory data showed non-reactive HIV and hepatitis B and C serology. Patient received oral dexamethasone 40 mg/day for 4 days with gradual improvement in platelet count as shown in Fig. 3.