Sex: M
Vaccine: VARZOS
Symptoms: Blood smear test abnormal, Erythroblast morphology, Haemoglobin normal, Immune thrombocytopenia, Immunoglobulin therapy
Clinical narrative: Thrombocytopenia; several 5 mm purpuric blisters inside his mouth and on the inside upper lip, as well as small purpura at the site of an adhesive bandage on his left upper arm; petechiae on his bilateral lower extremities; bleeding oral blisters; This case was reported in a literature article and described the occurrence of thrombocytopenia in a 63-year-old male patient who received Herpes zoster (Shingrix) for prophylaxis. Acute Immune Thrombocytopenia following administration of Shingrix recombinant zoster vaccine.;  :  .DOI: 10.1002/ajh.26143)   The patient's past medical history included open angle glaucoma and hypercholesterolemia. Concurrent medical conditions included basal cell carcinoma.   On 1st September 2020, the patient received the 1st dose of Shingrix. On 15th September 2020, 14 days after receiving Shingrix, the patient experienced thrombocytopenia (serious criteria hospitalization and GSK medically significant), purpura (serious criteria hospitalization) and petechia (serious criteria hospitalization). In September 2020, the patient experienced blood blister (serious criteria hospitalization). The patient was treated with dexamethasone and immunoglobulins nos (Ivig). On 4th December 2020, the outcome of the thrombocytopenia was recovered/resolved. On an unknown date, the outcome of the blood blister, purpura and petechia were recovered/resolved.   The reporter considered the thrombocytopenia, blood blister, purpura and petechia to be related to Shingrix.  Additional details were provided as follows: This case was reported in a literature article and described the occurrence of acute immune thrombocytopenia in a 63-years old male patient, who was vaccinated with Shingrix (GlaxoSmithKline) for prophylaxis. The patient had a history of basal cell carcinomas of multiple skin sites, open-angle glaucoma, and hypercholesterolemia. No information on patient's medical history, family history, concurrent condition or concomitant medication was provided. On 1st September 2020, the patient received initial recombinant zoster (Shingrix) Vaccine (administration route and site unspecified, dosage unknown; batch number not provided). The age of vaccination was not provided but it could be 62 years or 63 years. On 15th September 2020, about 2 weeks after the vaccination, the patient presented to primary care physician with observation of bleeding oral blisters. The patient did not report any other abnormal bleeding or bruising, or associated fevers, chills, anorexia or weight loss. Physical exam revealed several 5 mm purpuric blisters inside his mouth and on the inside upper lip, as well as small purpura at the site of an adhesive bandage on his left upper arm, and petechiae on his bilateral lower extremities. A complete blood count (CBC) revealed a platelet count of 1000/uL. White blood cell count and hemoglobin were within normal limits. The patient was admitted to the general medicine service at which point Hematology was consulted. Review of the peripheral blood smear showed severe thrombocytopenia with rare large and giant platelets. Erythrocyte morphology was normal and there were no schistocytes or evidence of dysplasia. Isolated severe thrombocytopenia with giant platelets on the peripheral blood smear was thought to be consistent with ITP and Hematology recommended starting dexamethasone 40 mg daily with a plan to complete 4 days. The patient received 5 days of dexamethasone 40 mg daily between 15th September 20202 and 19th September 2020, and an extra dose was administered due to an order duplication. During this time his platelet count remained in the 0-1000/uL range. Given the lack of improvement in his platelet count and concern for risk of bleeding, he received IVIG 1 g/kg (total dose 75 g) on 21st September 2020. On 22nd September 2020 his platelet count had increased to 25000/uL, and he was discharged home on 23rd September 2020 with a platelet count of 30000/uL. On follow-up 29th September 2020 platelets had increased to 5900/uL and subsequently normalized at 268000/uL on 4th December 2020. This case has been considered as serious due to hospitalization. The author's commented, "While ITP following zoster vaccine has not been previously described, the temporal relation between administration of the shingles vaccine with development of ITP about 2 weeks later does suggest causality, particularly without other obvious triggers. Thrombocytopenia has been described following infection with varicella zoster in children both during acute infection and as a post-infectious sequelae occurring days to weeks after symptom resolution. The mechanism is thought to be development of IgG and IgM directed against platelet surface glycoproteins which occurs in the setting of viremia. Shingrix recombinant zoster vaccine does not contain live virus but rather contains zoster glycoprotein E combined with adjuvant ASO1B to promote sustained immune response. It stands to reason that this vaccine would induce a similar immune response as is seen in varicella zoster infection and may therefore induce IgG and IgM directed against platelet surface glycoproteins resulting in acute ITP. The patient in this case achieved a complete remission of his acute ITP following treatment with dexamethasone and IVIG."