Age: 50.0
Sex: M
Vaccine: FLUX
Symptoms: Coombs direct test positive, Ecchymosis, Evans syndrome, Flow cytometry, Gingival bleeding
Clinical narrative: This case was reported in a literature article and described the occurrence of Evans syndrome in a 50-year-old male subject who was vaccinated with Influenza vaccine (unspecified) (manufacturer unspecified). No medical history and no concomitant medications. No history of recent illness and denied tobacco, alcohol, or illicit drug use. The subject couldn't recall any trauma to his right hand. On an unspecified date, the subject received an unspecified dose of Influenza vaccine (unspecified) (administration site and route unknown, batch number not provided). 3 days after vaccination with Influenza vaccine (unspecified), the subject experienced gingival bleeding and painless discoloration of his right hand. On Emergency Department, 4 days after vaccination with Influenza vaccine (unspecified), the subject had bilateral petechial lesions to the sclera with no icterus. On oral examination, he had multiple petechial lesions to the soft palate. There was no active bleeding. He also had ecchymosis to the right thenar eminence and purpuric rash over the left forearm. The subject's heart, lungs and abdominal examinations were unremarkable and he had no evidence of lymphadenopathy or hepatosplenomegaly. Laboratory tests revealed a white blood cell count of 3.6 k/uL, hemoglobin 15 g/dL, hematocrit 42%, and platelet count less than 5 k/uL. The subjects peripheral blood smear showed thrombocytopenia with no schistocytes, and no other abnormalities. The subjects prothrombin time, partial thromboplastin time, and liver function tests were all within normal limits, and his HIV and hepatitis A, B, and C serology tests were negative. Abdominal ultrasound demonstrated a normal size spleen with no other abnormalities. Evan's syndrome was diagnosed. The subject was hospitalised. The subject was treated with prednisolone with no improvement in the platelet count. On the 3rd hospital day, the subject was treated with normal Immunoglobulin. His platelet count gradually improved and on the 6th hospital day, his platelet count was 70 k/uL. The subject was discharged and was prescribed a Prednisone taper. 1 week after discharge, the subject complained of gingival bleeding. His laboratory evaluation revealed WBC 20.6 k/mL, Hb 8.7 g/dL, Hct 25%, and PLT less than 5 k/mL. The lactate dehydrogenase was elevated at 1140 U/L, and the DAT (anti-IgG) was positive. The peripheral blood smear showed thrombocytopenia with occasional spherocytes and no other abnormalities. Bone marrow aspirate and core biopsy revealed hypercellular marrow with erythroid and megakaryocytic hyperplasia. There was a mild to moderate left shift of the red cell precursors and megakaryocytes. Flow cytometry showed a normal cell profile with less than 1% blasts. The lymphocytes were phenotypically normal with polyclonal B cells and plasma cells. No features of neoplasia were found. After treatment with Methylprednisolone and IVIG, the subject gradually improved and was discharged after 5 days. Laboratory results on the day of discharge revealed WBC 15 k/mL, Hb 9.1 g/dL, Hct 27%, and PLT 119 k/mL. At the 2-week follow up, the patient's PLT count had improved to 200 k/mL. At the time of reporting, the outcome of the events was unspecified. Summary of the literature article: Evans syndrome is an uncommon condition defined by the combination (either simultaneously or sequentially) of immune thrombocytopenia purpura and autoimmune hemolytic anemia with a positive direct antiglobulin test in the absence of known underlying etiology. The authors described a case of a 50-year-old man with no prior medical history who developed Evans syndrome 4 days after receiving influenza immunization. The patient improved following treatment with oral prednisone and intravenous immunoglobulin. The author's conclusion state that Influenza vaccine is one of the most commonly used vaccines worldwide, with millions of people being vaccinated annually. Despite its wide use, only sparse information has been published concerning any hematological effects of this vaccine. The rarity of such effects supports the safety of using this vaccine.