Age: 82.0
Sex: M
Vaccine: VARZOS
Symptoms: Blood fibrinogen increased, Coagulation test normal, Haemoglobin decreased, Malaise, Pain
Clinical narrative: Patient is an 82yo man with PMH significant for remote h/o prostate cancer treatment with IMRT (no hormone tx) 12 years ago and HTN, who presented to the ED with diffuse petecchiae and was found to have a PLT count of 0. Patient reports being in his usual state of excellent health until 2 days ago, when he had a routine PCP visit during which he received the Shingrix vaccine. The following day, he developed diffuse body aches and malaise, and started noticing petecchiae on his LEs and face. No other bleeding including no gum bleeding, hemoptysis, hematuria, or blood in his stool or dark stools. Of note, he was prescribed Ibuprofen by his PCP for a painful toe about a week ago, which had had been taking for 3-4 days prior to admission and takes a baby aspirin nightly. Did not had fevers at home, no periods of confusion or altered MS, no recent unintentional weight loss, fever/chills or drenching sweats.   Patient was seen by Hem/Onc. The differential for thrombocytopenia was wide. TTP was thought to be unlikely as there was no increase in schistocytes on smear, Hgb was normal (12g/L), and pt didn't have any renal dysfunction. In terms of HIT, he did not have recent exposure to heparin, has not been hospitalized recently. Other considerations included thrombocytopenia due to new medications (recently started Ibuprofen, which could be a possible culprit), sequestration (no e/o splenomegaly on exam, and one would not expect such a dramatic drop in PLT counts), no h/o excessive alcohol use. DIC in the setting of an acute infection or malignancy was also thought to be possible, but patient's coags were normal, and fibrinogen is elevated, essentially ruling out DIC. Severe nutritional deficiencies can also cause thrombocytopenia but again, Heme/Onc reports would not expect such a severe degree of thrombocytopenia so acutely and would also expect some degree of anemia.   Most likely on the Heme/Onc differential is immune thrombocytopenia most likely caused by Shingrix vaccine he received on 6/12/19, 1 day prior to onset of symptoms, based on the close temporal relationship. Heme/Onc providers found no published case reports of this, however, in the FDA approval document for Shingrix, there is mention of 5 cases of thrombocytopenia observed during the study period (4 in the Shingrix group and 1 in the placebo group), however, all of these were observed after 100 days post-vaccination and after the second dose of the vaccine. Degree of thrombocytopenia is not reported in the document. Such severe and acute onset of thrombocytopenia has not been reported to our knowledge.  Patient was started on dexamethasone 40mg PO QAM for 4 days total, received 1 g/kg/day x2 days, and received 2 units of pooled platelets. His platelet count recovered from 0--> 7 --> 14 --> 16 --> 24 --> 34 over the course of his hospitalization (6/14-6/16). Patient was discharged with plan to complete dexamethasone course and to recheck platelet count in 5 days. Symptoms: Rash, Purpura & THROMBOCYTOPENIA (platelets 0) Treatment: DEXAMETHASONE 40 MG EVERY DAY, GLOBULIN IMMUNE 67 GM ONCE, GLOBULINIMMUNE 67 GM ONCE