Thrombocytopenic purpura vaccine

Idiopathic thrombocytopenic purpura, also referred to as immune thrombocytopenic purpura, is a bleeding disorder characterised by destruction of platelets. Antiplatelet autoantibodies are present, suggesting an autoimmune aetiology. These antibodies label the platelets for destruction by macrophages in the spleen. The condition may be acute or chronic. Acute ITP is the most common form and is found most often in children. Some cases are associated with recent viral infections and immunisations, notably the measles, mumps, rubella (MMR) vaccine. Typically, the disease is transient with no evidence of vaccine-associated recurrence. The peak incidence occurs between the ages of... 

A healthy 7-year-old girl developed thrombocytopenic purpura after hepatitis B immunization, three doses of vaccine every month followed by a booster (47). 

Maezono R, Escobar AM. Purpura trombocitopenico apos vacina de hepatite B. [Thrombocytopenic purpura after hepatitis B vaccine.] J Pediatr (Rio J) 2000 76(5) 395-8. 

Finielz P, Lam-Kam-Sang LF, Guiserix J. Systemic lupus erythematosus and thrombocytopenic purpura in two members of the same family following hepatitis B vaccine. Nephrol Dial Transplant 1998 13(9) 2420-1. 

Casoli P, Tumiati B. Porpora trombocitopenica idiopatica acuta dopo vaccinacione antinfluenzale. [Acute idiopathic thrombocytopenic purpura after anti-influenza vaccination.] Medicina (Firenze) 1989 9(4) 417-18. 

However, the authors of the report of the Institute of Medicine, National Academy of Sciences, Washington, DC (1991) entitled Adverse Effects of Pertussis and Rubella Vaccines (38) considered that there was insufficient evidence to indicate either the presence or absence of a causal relation between RA 27/3 rubella vaccine and thrombocytopenic purpura. 

There is a relation between MMR vaccination and thrombocytopenic purpura, but not with the measles component itself (18). Thrombocytopenic purpura after MMR has been reviewed, with discussion of pathogenesis and the vaccines and infections associated with this problem (83). Rubella vaccine is one of the most frequently reported causes of thrombocytopenia in Denmark (84). In France, a retrospective epidemiological survey (1984-92) showed that the rates of thrombocytopenic purpura per 100 000 vaccinees were 0.23 for measles vaccine, 0.17 for rubella vaccine, 0.87 for combination MR vaccine, and 0.95 for MMR vaccine (85). Thrombocytopenia was severe and always associated with purpura. Cases of recurrent thrombocytopenic purpura after repeated MMR immunization have been reported (86,87). The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has recommended avoiding subsequent doses of MMR when a previous episode of thrombocytopenia occurred in close temporal proximity to the previous immunization, that is within 6 weeks (88,89). 

The causal relation between MMR vaccine and idiopathic thrombocytopenic purpura has been confirmed using linkage of immunization records and hospital admission records the absolute risk within 6 weeks of immunization was 1 per 22 300 doses (90). 

Nieminen U, Peltola H, Syqala MT, Makipemaa A, Kekomaki R. Acute thrombocytopenic purpura following measles, mumps and rubella vaccination. A report on 23 patients. Acta Paediatr 1993 82(3) 267-70. 

Chang SK, Farrell DL, Dougan K, Kobayashi B. Acute idiopathic thrombocytopenic purpura following combined vaccination against measles, mumps, and rubella. J Am Board Fam Pract 1996 9(l) 53-5. 

Autret E, Jonville-Bera AP, Galy-Eyraud C, Hessel L. Purpura thrombopenique apres vaccination isolee on asso-ciee centre la rougeole, la rubeole et les oreillous. [Thrombocytopenic purpura after isolated or combined vaccination against measles, mumps and rubella.] Therapie 1996 51(6) 677-80. 

Vlacha V, Forman EN, Miron D, Peter G. Recurrent thrombocytopenic purpura after repeated measles-mumps-rubella vaccination. Pediatrics 1996 97(5) 738-9. 

Thrombocytopenic purpura is a rare comphcation of smallpox vaccination (46). Postvaccinial lymphadenitis can occur (47). 

Burke PJ, Shah NR. Thrombocytopenic purpura after smallpox vaccine. Pa Med 1981 84(9) 49-50. 

An epidemiological and statistical method based on linkage of routinely available computerized hospital admission records with vaccination records has been described by Farrington (20). This active surveillance method has been used to assess the attributable risk of convulsions after DTP and MMR immunization and to investigate the relation between MMR vaccine and idiopathic thrombocytopenic purpura in children under 2 years of age in five districts in England. 

Measles in any combination MMR, MR, M A. Thrombocytopenic purpura B. Vaccine-strain measles viral infection in an immunodeficient recipient C. Any sequel (including death) of the above events D. Events described in the manufacturers package insert as contraindications to additional doses of the vaccine 7-30 days 6 months No limit See package insert... 

Miller E, Waight P, Farrington CP, Andrews N, Stowe J, Taylor B. Idiopathic thrombocytopenic purpura and MMR vaccine. Arch Dis Child 2001 84(3) 227-9. 

Lee SY, Komp DM, Andiman W. Thrombocytopenic purpura following Varicella-zoster vaccination. Am J Pediatr Hematol Oncol 1986 8(l) 78-80. 

Hib Hemophilus influenzae type b HSCT hematopoietic stem cell transplant IMIG intramuscular immunoglobulin IPV inactivated polio vaccine ITP immune thrombocytopenic purpura IVIG intravenous immunoglobulin LAIV live attenuated influenza vaccine MMR measles-mumps-rubeUa vaccine OPV oral polio vaccine... 

Hematologic A 3-year-old boy developed immune thrombocytopenic purpura 26 days after a second dose of seasonal influenza vaccine [12. He was given intravenous immunoglobulin and recovered within 2 days. A literature review showed that symptomatic thrombocytopenia occurs in a substantial number of children and adults who require hospitalization for complicated natural influenza infections. In contrast, reports of immune thrombocytopenic purpura after influenza immunization are rare and occur in adults. 

Hematologic The incidence of immune thrombocytopenic purpura after measles-mumps-rubella (MMR) immunization and the risk of recurrence after repeat immunization have been compared with the incidence after natural measles and rubella in a systematic review [19 ]. On the basis of 12 studies, the incidence of MMR-associated immune thrombocytopenic purpura was 0.087-4 (median 2.6) cases per 100000 vaccine doses. Severe bleeding was rare, and MMR-associated thrombocytopenia resolved within 6 months from diagnosis in 93% of cases. MMR vaccination of unimmunized patients with immune thrombocytopenic purpura and revaccination of patients with prior disease did not lead to recurrence. The authors concluded that MMR-associated immune thrombocytopenic purpura is rare, self-limiting, and non-life-threatening, and that susceptible children with immune thrombocytopenic purpura should be immunized with MMR at the recommended ages. 

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(6) e227-9. 

Mantadakis E, Farmaki E, Buchanan GR. Thrombocytopenic purpura after measles-mumps-rubella vaccination a systematic review of the literature and guidance for management. J Pediatr 2010 156 623-8. 

A 34-year-old woman with immune thrombocytopenic purpura was treated with splenectomy and was immunized against pneumococci, meningococci, and Haemophilus influenzae type b. She had been well for 3 years, but 2 weeks after a first dose of tick-borne encephalitis vaccine (FSME-Immun, Baxter ), her platelet count fell to 37 x 10 /l. She was given dexamethasone 40 mg/day for 4 days and her platelet count normalized and remained stable. 

Benz R, Krause M, Tavema C. Immune thrombocytopenic purpura reactivation after tick-borne encephahtis vaccination. Vaccine 2009 27 5172-3. 

England and Deranark demonstrated that this collaborative approach worked well when they used a common protocol and analysis, and provided individual estimates consistent with the established risk of thrombocytopenic purpura following measles-mumps-rubella (MMR) vaccination [4 ]. 

Andrews N, Stowe J, Miller E, Svanstrom H, Johansen K, Bonhoeffer J, et aL A collaborative approach to investigating the risk of thrombocytopenic purpura after measles-rniumps- iibetla vaccination in England and Denmark. Vaccine 2012 30(19) 3042-6. 

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