Sex: M
Vaccine: FLUX, PPV
Symptoms: Immune thrombocytopenic purpura, Immunoglobulin therapy, Laboratory test abnormal, Lymphoproliferative disorder, Mouth haemorrhage
Clinical narrative: Initial information received on 20-May-2019 regarding an unsolicited valid serious case issued from a literature article. Summary Epistaxis may be attributed to many causes during the winter including dry mucous membranes from low indoor humidity from heating. However, epistaxis may also be due to thrombocytopaenia. Immune thrombocytopaenia purpura (ITP) is an autoimmune disorder causing thrombocytopaenia. Viral infections sometimes lead to ITP. Vaccines, predominantly the measles-mumps-rubella vaccine, have been associated with the development of ITP. There are several published case reports regarding influenza vaccine induced ITP. However, an association between ITP and influenza vaccination has not been firmly proven yet. We report the case of an adult with three episodes of epistaxis, each within 1 week of receiving a yearly influenza trivalent inactivated vaccine, the last episode being more severe and also featuring gross haematuria. This case involves a 68 years old male patient who experienced severe thrombocytopaenia, thrombocytopaenia secondary to lymphoproliferative disorder, severe thrombocytopaenia due to primary immune thrombocytopaenia purpura (itp). and hepatitis c., while he received vaccines PNEUMOCOCCAL CONJUGATE VACCINE and INFLUENZA VACCINE. The patient's past medical history included Hepatitis C with (diagnosed 4 years prior, treatment with ledispavir/sofosbuvir having been completed 2 months prior)., Glucose tolerance impaired, Hypertriglyceridaemia, Back pain, Anxiety, Cholecystectomy and Tonsillectomy. The patient's past medical treatment included tamsulosin with 0.4 mg daily, fenofibrate with 145 mg daily, fenofibrate with 145 mg daily, fluticasone with 50 mg and aspirin.the patient's past vaccination(s) and family history were not provided. At the time of the event, the patient had ongoing Ex-tobacco user. On an unknown date, the patient received a  dose of suspect INFLUENZA VACCINE produced by unknown manufacturer lot number not reported. On an unknown date, the patient received a  dose of suspect PNEUMOCOCCAL CONJUGATE VACCINE not produced by Sanofi Pasteur lot number not reported via unknown route On an unknown date , The patient developed a serious severe thrombocytopaenia (thrombocytopenia), thrombocytopaenia secondary to lymphoproliferative disorder (lymphoproliferative disorder), severe thrombocytopaenia due to primary immune thrombocytopaenia purpura (itp). (immune thrombocytopenic purpura),  hepatitis c. (hepatitis c), epistaxis, gross haematuria (frank haematuria), bleeding gums/bleeding oral (gingival bleeding), bleeding oral ulcers. (ulcer haemorrhage) following the administration of INFLUENZA VACCINE and  PNEUMOCOCCAL CONJUGATE VACCINE. The patient was hospitalized for these events. Relevant laboratory test results included: Blood glucose (65 - 99 mg/dL) - On an unknown date: 104 mg/dL [104] Fibrin D dimer increased (0.00 - 0.50 mg/L) - On an unknown date: 2.09 mg/L [2.09] Red blood cell abnormality (0 - 3 10*9/L) - On an unknown date: >100 10*9/L [?100] Final diagnosis was hepatitis c., severe thrombocytopaenia due to primary immune thrombocytopaenia purpura (itp)., thrombocytopaenia secondary to lymphoproliferative disorder and severe thrombocytopaenia. Patient received a platelet transfusion. He was initiated on both intravenous immunoglobulin (IVIG) therapy and dexamethasone 40 mg daily for 3 days. He was then switched to oral prednisone 60 mg daily. All told, the patient received four transfusions of platelets during the admission given his platelet count of 0/µL and bleeding from both the nose and the urinary tract The patient outcome is reported as Recovered / Resolved on an unknown date for epistaxis, as Unknown for gross haematuria, as Unknown for severe thrombocytopaenia, as Unknown for bleeding gums/bleeding oral, as Unknown for bleeding oral ulcers., as Unknown for thrombocytopaenia secondary to lymphoproliferative disorder, as Unknown for severe thrombocytopaenia due to primary immune thrombocytopaenia purpura (itp). and as Unknown for hepatitis c. (The patient continues to follow-up. It has now been one and a half years. He has never had another abnormal platelet count or any episodes of bleeding). Information on the batch number was requested.; Sender's Comments: Patient presented with thrombocytopaenia along with associated symptoms after vaccination.Time to onset is unknown. Moreover, further information including patient's medical history, concomitant medications, previous vaccination and tolerance, laboratory investigations excluding other etiology would be needed to fully assess this case. Based on available information the role of individual vaccine cannot be assessed.