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Immune thrombocytopenic purpura (ITP) associated with vaccinations: a review of reported cases

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Abstract

Immune thrombocytopenic purpura (ITP) is an autoimmune condition characterized by low platelet count with mucocutaneous and other bleedings. Clinical manifestations may range from spontaneous formation of purpura and petechiae, especially on the extremities, to epistaxis, bleeding at the gums or menorrhagia, any of which occur usually if the platelet count is below 20,000 per μl. A very low count may result in the spontaneous formation of hematomas in the mouth or on other mucous membranes. Fatal complications, including subarachnoid or intracerebral, lower gastrointestinal or other internal bleeding can arise due to an extremely low count. Vaccines may induce ITP by several mechanisms. Vaccine-associated autoimmunity may stem not only from the antigen-mediated responses but also from other constituents of the vaccine, such as yeast proteins, adjuvants, and preservatives diluents. The most likely is through virally induced molecular mimicry. The binding of pathogenic autoantibodies to platelet and megakaryocytes may cause thrombocytopenia by different mechanisms, such as opsonization, direct activation of complement, or apoptotic pathways. The autoantibodies hypothesis is not sufficient to explain all ITP cases: In the anti-platelet antibody-negative cases, a complementary mechanism based on T cell immune-mediated mechanism has been suggested. In particular, T cell subsets seem dysregulated with an increased production of pro-inflammatory cytokines, as IFN-γ and TNF, and chemokines, as CXCL10. Vaccines are one of the most striking discoveries in human history that changed dramatically life expectancy. Nonetheless, the occurrence of adverse events and autoimmune phenomena has been described following vaccination, and ITP may represent one of this.

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References

  1. McCrae K. Immune thrombocytopenia: no longer “idiopathic”. Cleve Clin J Med. 2011;78:358–73.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Schwartz RS. Immune thrombocytopenic purpura–from agony to agonist. N Engl J Med. 2007;357:2299–301.

    Article  CAS  PubMed  Google Scholar 

  3. Luiken GA, McMillan R, Lightsey AL, et al. Platelet-associated IgG in immune thrombocytopenic purpura. Blood. 1977;50:317–25.

    CAS  PubMed  Google Scholar 

  4. Rodeghiero F, Stasi R, Gernsheimer T, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009;113:2386–93.

    Article  CAS  PubMed  Google Scholar 

  5. Arkfeld DG, Weitz IC. Immune thrombocytopenia in patients with connective tissue disorders and the antiphospholipid antibody syndrome. Hematol Oncol Clin North Am. 2009;23:1239–49.

    Article  PubMed  Google Scholar 

  6. Provan D. Characteristics of immune thrombocytopenic purpura: a guide for clinical practice. Eur J Haematol. 2009;Suppl71:8–12.

    Article  Google Scholar 

  7. Takahashi T, Yujiri T, Shinohara K, et al. Molecular mimicry by Helicobacter pylori CagA protein may be involved in the pathogenesis of H. pylori-associated chronic idiopathic thrombocytopenic purpura. Br J Haematol. 2004;124:91–6.

    Article  CAS  PubMed  Google Scholar 

  8. Stasi R, Sarpatwari A, Segal JB, et al. Effects of eradication of Helicobacter pylori infection in patients with immune thrombocytopenic purpura: a systematic review. Blood. 2009;113:1231–40.

    Article  CAS  PubMed  Google Scholar 

  9. Yenicesu I, Yetgin S, Ozyürek E, Aslan D. Virus-associated immune thrombocytopenic purpura in childhood. Pediatr Hematol Oncol. 2002;19:433–7.

    Article  PubMed  Google Scholar 

  10. De Mattia D, Del Vecchio GC, Russo G, et al. Management of chronic childhood immune thrombocytopenic purpura: AIEOP consensus guidelines. Acta Haematol. 2010;123:96–109.

    Article  PubMed  Google Scholar 

  11. Yong M, Schoonen WM, Li L, et al. Epidemiology of paediatric immune thrombocytopenia in the general practice research database. Br J Haematol. 2010;149:855–64.

    Article  PubMed  Google Scholar 

  12. Shlamovitz GZ, Johar S. A case of Evans’ syndrome following influenza vaccine. J Emerg Med. 2013;44:e149–51.

    Article  PubMed  Google Scholar 

  13. Tishler M, Levy O, Amit-Vazina M. Immune thrombocytopenic purpura following influenza vaccination. Isr Med Assoc J. 2006;8:322–3.

    PubMed  Google Scholar 

  14. Rondina MT, Brewster B, Grissom CK, et al. In vivo platelet activation in critically ill patients with primary 2009 influenza AH1N1. Chest. 2012;141:1490–5.

    Article  PubMed Central  PubMed  Google Scholar 

  15. Armstrong SM, Darwish I, Lee WL. Endothelial activation and dysfunction in the pathogenesis of influenza A virus infection. Virulence. 2013;4:537–42.

    Article  PubMed  Google Scholar 

  16. Shoenfeld Y, Agmon-Levin N. ‘ASIA’—autoimmune/inflammatory syndrome induced by adjuvants. J Autoimmun. 2011;36:4–8.

    Article  CAS  PubMed  Google Scholar 

  17. Olsson B, Ridell B, Jernås M, Wadenvik H. Increased number of B-cells in the red pulp of the spleen in ITP. Ann Hematol. 2012;91:271–7.

    Article  PubMed  Google Scholar 

  18. Li R, Emsley J. The organizing principle of the platelet glycoprotein Ib-IX-V complex. J Thromb Haemost. 2013;11:605–14.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  19. Cines DB, Liebman H, Stasi R. Pathobiology of secondary immune thrombocytopenia. Semin Hematol. 2009;46:S2–14.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Okazaki N, Takeguchi M, Sonoda K, et al. Detection of platelet-binding anti-measles and anti-rubella virus IgG antibodies in infants with vaccine-induced thrombocytopenic purpura. Vaccine. 2011;29:4878–80.

    Article  PubMed  Google Scholar 

  21. Emmerich F, Bal G, Barakat A, et al. High-level serum B-cell activating factor and promoter polymorphisms in patients with idiopathic thrombocytopenic purpura. Br J Haematol. 2007;136:309–14.

    Article  CAS  PubMed  Google Scholar 

  22. Liu XG, Hou M. Immune thrombocytopenia and B-cell-activating factor/a proliferation-inducing ligand. Semin Hematol. 2013;50:S89–99.

    Article  CAS  PubMed  Google Scholar 

  23. Catani L, Fagioli ME, Tazzari PL, et al. Dendritic cells of immune thrombocytopenic purpura ITP show increased capacity to present apoptotic platelets to T lymphocytes. Exp Hematol. 2006;34:879–87.

    Article  CAS  PubMed  Google Scholar 

  24. Yu H, Liu Y, Han J, et al. TLR7 regulates dendritic cell-dependent B-cell responses through BlyS in immune thrombocytopenic purpura. Eur J Haematol. 2011;86:67–74.

    Article  CAS  PubMed  Google Scholar 

  25. Chang M, Nakagawa PA, Williams SA, et al. Immune thrombocytopenic purpura ITP plasma and purified ITP monoclonal autoantibodies inhibit megakaryocytopoiesis in vitro. Blood. 2003;102:887–95.

    Article  CAS  PubMed  Google Scholar 

  26. McMillan R, Wang L, Tomer A, Nichol J, Pistillo J. Suppression of in vitro megakaryocyte production by antiplatelet autoantibodies from adult patients with chronic ITP. Blood. 2004;103:1364–9.

    Article  CAS  PubMed  Google Scholar 

  27. Gu D, Chen Z, Zhao H, et al. Th1 CXCL10 and Th2 CCL2 chemokine expression in patients with immune thrombocytopenia. Hum Immunol. 2010;71:586–91.

    Article  CAS  PubMed  Google Scholar 

  28. Sakakura M, Wada H, Tawara I, et al. Reduced Cd4+ Cd25+ T cells in patients with idiopathic thrombocytopenic purpura. Thromb Res. 2007;120:187–93.

    Article  CAS  PubMed  Google Scholar 

  29. Yu J, Heck S, Patel V, et al. Defective circulating CD25 regulatory T cells in patients with chronic immune thrombocytopenic purpura. Blood. 2008;112:1325–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  30. Zhang J, Ma D, Zhu X, Qu X, Ji C, Hou M. Elevated profile of Th17, Th1 and Tc1 cells in patients with immune thrombocytopenic purpura. Haematologica. 2009;94:1326.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  31. Rocha AM, Souza C, Rocha GA, et al. The levels of IL-17A and of the cytokines involved in Th17 cell commitment are increased in patients with chronic immune thrombocytopenia. Haematologica. 2011;96:1560–4.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  32. Cao J, Li XQ, Chen C, et al. Imbalance of Th17/Treg cells ratio in peripheral blood of patients with immune thrombocytopenia. Zhongguo Shi Yan Xue Ye Xue Za Zhi. 2011;19:730–3.

    PubMed  Google Scholar 

  33. Olsson B, Andersson PO, Jernås M, et al. T-cell-mediated cytotoxicity toward platelets in chronic idiopathic thrombocytopenic purpura. Nat Med. 2003;9:1123–4.

    Article  CAS  PubMed  Google Scholar 

  34. Rinaldi M, Perricone C, Ortega-Hernandez OD, Perricone R, Shoenfeld Y. Immune thrombocytopaenic purpura: an autoimmune cross-link between infections and vaccines. Lupus. 2014;23:554–67.

    Article  CAS  PubMed  Google Scholar 

  35. Shoenfeld Y. Infections, vaccines and autoimmunity. Lupus. 2009;18:1127–8.

    Article  CAS  PubMed  Google Scholar 

  36. Garbe E, Andersohn F, Bronder E, et al. Drug-induced immune thrombocytopaenia: results from the Berlin Case-Control Surveillance Study. Eur J Clin Pharmacol. 2012;68:821–32.

    Article  CAS  PubMed  Google Scholar 

  37. Moulis G, Sommet A, Sailler L, Lapeyre-Mestre M, Montastruc JL, French Association Of Regional Pharmacovigilance Centers. Drug-induced immune thrombocytopenia: a descriptive survey in the French PharmacoVigilance database. Platelets. 2012;23:490–4.

    Article  CAS  PubMed  Google Scholar 

  38. Yasuda H, Nagata M, Moriyama H, et al. Development of fulminant Type 1 diabetes with thrombocytopenia after influenza vaccination: a case report. Diabet Med. 2012;29:88–9.

    Article  CAS  PubMed  Google Scholar 

  39. Mantadakis E, Farmaki E, Thomaidis S, Tsalkidis A, Chatzimichael A. A case of immune thrombocytopenic purpura after influenza vaccination: consequence or coincidence? J Pediatr Hematol Oncol. 2010;32:e227–9.

    Article  PubMed  Google Scholar 

  40. Tsuji T, Yamasaki H, Tsuda H. Refractory idiopathic thrombocytopenic purpura following influenza vaccination. Rinsho Ketsueki. 2009;50:577–9.

    PubMed  Google Scholar 

  41. Mamori S, Amano K, Kijima H, Takagi I, Tajiri H. Thrombocytopenic purpura after the administration of an influenza vaccine in a patient with autoimmune liver disease. Digestion. 2008;77:159–60.

    Article  PubMed  Google Scholar 

  42. Granier H, Nicolas X, Laborde JP, Talarmin F. Severe autoimmune thrombopenia following anti-influenza vaccination. Presse Med. 2003;32:1223–4.

    PubMed  Google Scholar 

  43. Jin CQ, Dong HX, Sun ZX, et al. Acute immune thrombocytopenic purpura as adverse reaction to oral polio vaccine OPV. Hum Vaccin Immunother. 2013;9:1739–40.

    Article  PubMed Central  PubMed  Google Scholar 

  44. Casoli P, Tumiati B. Acute idiopathic thrombocytopenic purpura after anti-influenza vaccination. Medicina Firenze. 1989;9:417–8.

    CAS  PubMed  Google Scholar 

  45. Kelton JG. Vaccination-Associated relapse of immune thrombocytopenia. JAMA. 1981;245:369–70.

    Article  CAS  PubMed  Google Scholar 

  46. Brodin-Sartorius A, Guebre-Egziabher F, Fouque D, et al. Recurrent idiopathic thrombotic thrombocytopenic purpura: a role for vaccination in disease relapse? Am J Kidney Dis. 2006;48:e31–4.

    Article  PubMed  Google Scholar 

  47. Isai A, Durand J, Le Meur S, Hidalgo-Simon A, Kurz X. Autoimmune disorders after immunisation with Influenza A/H1N1 vaccines with and without adjuvant: EudraVigilance data and literature review. Vaccine. 2012;30:7123–9.

    Article  CAS  PubMed  Google Scholar 

  48. Huang WT, Huang WI, Huang YW, Hsu CW, Chuang JH. The reporting completeness of a passive safety surveillance system for pandemic H1N1 2009 vaccines: a capture-recapture analysis. Vaccine. 2012;30:2168–72.

    Article  PubMed  Google Scholar 

  49. Markovic-Plese S, Hemmer B, Zhao Y, Simon R, Pinilla C, Martin R. High level of cross-reactivity in influenza virus hemagglutinin-specific CD4+ T-cell response: implications for the initiation of autoimmune response in multiple sclerosis. J Neuroimmunol. 2005;169:31–8.

    Article  CAS  PubMed  Google Scholar 

  50. Tsang P, Gorse GJ, Strout CB, et al. Immunogenicity and safety of Fluzone® intradermal and high-dose influenza vaccines in older adults ≥65 years of age: a randomized, controlled, phase II trial. Vaccine. 2014;32:2507–17.

    Article  CAS  PubMed  Google Scholar 

  51. Jin Cheng-Giang, Dong Hai-xin, Sun Zhuo-xiang, et al. Acute immune thrombocytopenic purpura as adverse reaction to oral polio vaccine OPV. Hum Vaccin Immunother. 2013;9:1739–40.

    Article  PubMed Central  PubMed  Google Scholar 

  52. Wang JD, Huang FL, Chen PY, Wang TM, Chi CS, Chang TK. Acute immune thrombocytopenic purpura in infants: associated factors, clinical features, treatment and long-term outcome. Eur J Haematol. 2006;77:334–7.

    Article  PubMed  Google Scholar 

  53. Wise RP, Iskander J, Pratt RD, et al. Postlicensure safety surveillance for 7-valent pneumococcal conjugate vaccine. JAMA. 2004;292:1702–10.

    Article  CAS  PubMed  Google Scholar 

  54. Jackson LA, Gurtman A, Rice K, et al. Immunogenicity and safety of a 13-valent pneumococcal conjugate vaccine in adults 70 years of age and older previously vaccinated with 23-valent pneumococcal polysaccharide vaccine. Vaccine. 2013;31:3585–93.

    Article  CAS  PubMed  Google Scholar 

  55. Perricone C, Colafrancesco S, Mazor RD, Soriano A, Agomn-Levin N, Shoenfeld Y. Autoimmune/inflammatory syndrome induced by adjuvants ASIA 2013: unveiling the pathogenic, clinical and diagnostic aspects. J Autoimmun. 2013;47:1–16.

    Article  CAS  PubMed  Google Scholar 

  56. Ronchi F, Cecchi P, Falcioni F, et al. Thrombocytopenic purpura as adverse reaction to recombinant hepatitis B vaccine. Arch Dis Child. 1998;78:273–4.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  57. Poullin P, Gabriel B. Thrombocytopenic purpura after recombinant hepatitis B vaccine. Lancet. 1994;344:1293.

    Article  CAS  PubMed  Google Scholar 

  58. Meyboom RH, Fucik H, Edwards IR. Thrombocytopenia reported in association with hepatitis B and A vaccines. Lancet. 1995;345:1638.

    Article  CAS  PubMed  Google Scholar 

  59. Neau D, Bonnet F, Michaud M, et al. Immune thrombocytopenic purpura after recombinant hepatitis B vaccine: retrospective study of seven cases. Scand J Infect Dis. 1998;30:115–8.

    Article  CAS  PubMed  Google Scholar 

  60. Geier DA, Geier MR. A case-control study of serious autoimmune adverse events following hepatitis B immunization. Autoimmunity. 2005;38:295–301.

    Article  CAS  PubMed  Google Scholar 

  61. Polat A, Akca H, Dagdeviren E. Severe thrombocytopenia after hepatitis B vaccine in an infant from Turkey. Vaccine. 2008;26:6495–6.

    Article  PubMed  Google Scholar 

  62. Hsieh YL, Lin LH. Thrombocytopenic purpura following vaccination in early childhood: experience of a medical center in the past 2 decades. J Chin Med Assoc. 2010;73:634–7.

    Article  PubMed  Google Scholar 

  63. Bertuola F, Morando C, Menniti-Ippolito F, et al. Association between drug and vaccine use and acute immune thrombocytopenia in childhood: a case-control study in Italy. Drug Saf. 2010;33:65–7.

    Article  CAS  PubMed  Google Scholar 

  64. O’Leary ST, Glanz JM, McClure DL, et al. The risk of immune thrombocytopenic purpura after vaccination in children and adolescents. Pediatrics. 2012;129:248–55.

    Article  PubMed  Google Scholar 

  65. Sauvè LJ, Bettinger J, Scheifele D, et al. Postvaccination thrombocytopenia in Canada. Pediatr Infect Dis J. 2010;29:559–61.

    PubMed  Google Scholar 

  66. Grimaldi-Bensouda L, Michel M, Aubrun E, et al. A case-control study to assess the risk of immune thrombocytopenia associated with vaccines. Blood. 2012;120:4938–44.

    Article  CAS  PubMed  Google Scholar 

  67. Sharma SK, Seth T, Agrawal N, Mahapatra M, Mishra P. Immune thrombocytopenic purpura following anti-rabies vaccines. Platelets. 2012;23:317–8.

    Article  CAS  PubMed  Google Scholar 

  68. Benz R, Krause M, Taverna C. Immune thrombocytopenic purpura reactivation after tick-borne encephalitis vaccination. Vaccine. 2009;27:5172–3.

    Article  CAS  PubMed  Google Scholar 

  69. Grimaldi-Bensouda L, Guillemot D, Godeau B, et al. Autoimmune disorders and quadrivalent human papillomavirus vaccination of young female subjects. J Intern Med. 2014;275:340–98.

    Article  Google Scholar 

  70. Pugnet G, Ysebaert L, Bagheri H, Montastruc JL, Laurent G. Immune thrombocytopenic purpura following human papillomavirus vaccination. Vaccine. 2009;27:3690.

    Article  PubMed  Google Scholar 

  71. Szenborn L, Czajka H, Brzostek J, et al. A randomized, controlled trial to assess the immunogenicity and safety of a heptavalent diphtheria, tetanus, pertussis, hepatitis B, poliomyelitis, hib and meningococcal serogroup C combination vaccine administered at 2, 3, 4 and 12–18 months of age. Pediatr Infect Dis J. 2013;32:777–85.

    Article  PubMed  Google Scholar 

  72. Drachtman RAl, Murphy S, Ettinger LJ. Exacerbation of chronic idiopathic thrombocytopenic purpura following measles-mumps-rubella immunization. Arch Pediatr Adolesc Med. 1994;148:326–7.

    Article  CAS  PubMed  Google Scholar 

  73. Vlacha V, Forman EN, Miron D, Peter G. Recurrent thrombocytopenic purpura after repeated measles-mumps-rubella vaccination. Pediatrics. 1996;97:738–9.

    CAS  PubMed  Google Scholar 

  74. Nieminen U, Peltola H, Syrjälä MT, Mäkipernaa A, Kekomäki R. Acute thrombocytopenic purpura following measles, mumps and rubella vaccination. A report on 23 patients. Acta Paediatr. 1993;82:267–70.

    Article  CAS  PubMed  Google Scholar 

  75. Beeler J, Varricchio F, Wise R. Thrombocytopenia after immunization with measles vaccines: review of the vaccine adverse events reporting system 1190–1994. Pediatr Infect Dis J. 1996;15:88–90.

    Article  CAS  PubMed  Google Scholar 

  76. Miller E, Waight P, Farrington CP, et al. Idiopathic thrombocytopenic purpura and MMR vaccine. Arch Dis Child. 2001;84:227–9.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  77. Black C, Kaye JA, Jick H. MMR vaccine and idiopathic thrombocytopaenic purpura. Br J Clin Pharmacol. 2003;55:107–11.

    Article  PubMed Central  PubMed  Google Scholar 

  78. Bibby AC, Farrell A, Cummins M, Erlewyn-Lajeunesse M. Is MMR immunisation safe in chronic idiopathic thrombocytopenic purpura? Arch Dis Child. 2008;93:354–5.

    Article  PubMed  Google Scholar 

  79. Stowe J, Kafatos G, Andrews N, Miller E. Idiopathic thrombocytopenic purpura and the second dose of MMR. Arch Dis Child. 2008;93:182–3.

    Article  PubMed  Google Scholar 

  80. British Committee for Standards in Haematology General Haematology Task Force. Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and in pregnancy. Br J Haematol. 2003;2003(120):574–96.

    Article  Google Scholar 

  81. McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS, Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, summary recommendations of the Advisory Committee on Immunization Practices ACIP. MMWR Recomm Rep. 2013;2013(62):1–34.

    Google Scholar 

  82. Ikegame K, Kaida K, Fujioka T, et al. Idiopathic thrombocytopenic purpura after influenza vaccination in a bone marrow transplantation recipient. Bone Marrow Transpl. 2006;38(4):323–4.

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Acknowledgements

Yehuda Shoenfeld has served as an expert witness in cases involving adverse vaccine reaction in the no-fault U.S. National Vaccine Injury Compensation Program.

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Authors and Affiliations

  1. Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy

    Carlo Perricone, Fulvia Ceccarelli, Fabrizio Conti & Guido Valesini

  2. Department of Internal Medicine A, Shaare Zedek Medical Center, Hebrew University Medical School, Jerusalem, Israel

    Gideon Nesher & Qasim Odeh

  3. The Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel

    Elisabetta Borella & Yehuda Shoenfeld

  4. Sackler Faculty of Medicine, Incumbent of the Laura Schwarz-Kip Chair for Research of Autoimmune Diseases, Tel-Aviv University, Tel Aviv, Israel

    Yehuda Shoenfeld

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  1. Carlo Perricone
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Perricone, C., Ceccarelli, F., Nesher, G. et al. Immune thrombocytopenic purpura (ITP) associated with vaccinations: a review of reported cases. Immunol Res 60, 226–235 (2014). https://doi.org/10.1007/s12026-014-8597-x

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