Severe, Refractory Immune Thrombocytopenia Occurring After SARS-CoV-2 Vaccine.
Severe, Refractory Immune Thrombocytopenia Occurring After SARS-CoV-2 Vaccine.
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DOI：
10.2147/jbm.s307047
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发表时间：
2021
影响因子：
2
通讯作者：
Tarantino MD
中科院分区：
文献类型：
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作者：
Helms JM;Ansteatt KT;Roberts JC;Kamatam S;Foong KS;Labayog JS;Tarantino MD
SARS-CoV-2疫苗的推出正在进行中，数百万人已经接种疫苗。美国疫苗不良事件报告系统（VAERS）中已添加了至少25份Moderna或辉瑞疫苗接种后的“免疫性血小板减少症”（ITP）或“血小板减少症”报告。ITP是一种罕见但已知的几种疫苗接种并发症。SARS-CoV-2疫苗是一种新的疫苗，具有新的作用机制，对疫苗接种后血小板减少症的流行病学、临床表现、治疗成功率和自然史的了解正在不断发展。我们报告一位74岁的男性在接受Moderna SARS-CoV-2疫苗后一天内出现难治性血小板减少症。接种疫苗后数小时，患者出现严重鼻衄和皮肤紫癜。第二天记录到重度血小板减少症，患者出现四肢无力和脑病伴面部肌肉无力。在14天内，首先使用高剂量地塞米松、静脉注射免疫球蛋白、血小板输注、利妥昔单抗、血浆置换（用于假定的急性炎性脱髓鞘性多发性神经病（AIDP））和每日4次血小板生成素受体激动剂（TPO-RA）艾曲泊帕（Promacta™）治疗血小板减少症，无血小板应答。三天后，他接受了TPO-RA romiplostim（Nplate™）。5天后，他的血小板计数开始上升，到接种后第25天，他的血小板计数在正常范围内。血小板减少症对一线和二线治疗难治。血小板计数的最终上升表明一种或两种TPO-RA可能影响了血小板的恢复。药物诱导的血小板减少症可能正在消退，但考虑到时间性，可能性较小。积极使用免疫抑制治疗可能会危及SARS-CoV-2疫苗的预期目的，应考虑早期使用非免疫抑制二线治疗疫苗相关的严重血小板减少症，如TPO-RA。虽然必须继续全球疫苗接种计划，但需要警惕疫苗接种后重度血小板减少症的发生。
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.