Thrombocytopenic Purpura
after Recombinant Hepatitis B Vaccine. A rare association
Venancio Conesa*, Mª Luz Nuñez**, Juan-Francisco
Navarro, Angela Mompel,* José Ruiz,* Amparo
Gómez*.
* Hematology Service, Public Health Service Hospital "General
Universitari d´Elx", Alicante; ** Microbiology Service,
Hospital "Virgen de la Arrixaca", Murcia, Spain
Correspondence: Venancio Conesa, C/ Isaac Peral nº4. Los
Belones, Cartagena, 30385 Murcia, Spain. Phone: +34. 68369532 -
Fax: +34.68269678
Abstract
Thrombocytopenic purpura is a well-known entity. In some occasions appears associated to systemic disorders. We report an uncommon case of thrombocytopenic purpura after recombinant hepatitis B vaccine and analyzed the clinical and laboratory features. Initial treatment with corticosteroid was successful and the patient is in complete remission.
Text
Side effects of recombinant
hepatitis B vaccine are infrequent, the most frequent being local
reactions. Of the systemic reactions, neurological manifestations
(polyradiculoneuritis, cerebellar ataxia, demyelination of the
central nervous system, etc.) and the autoimmune type
(polyarthritis, systemic lupus erythematosus, myalgia, ect) are
the most notable. However, hematological autoimmune phenomena are
very rare (Evan´s syndrome, autoimmune thrombocytopenia,
autoimmune hemolytic anemia, etc.).1-3 We describe the
case of a patient with thrombocytopenic purpura diagnosed
following administration of recombinant hepatitis B vaccine.
An 18 year old woman attended the emergency department with
purpura of her limbs and buccal cavity which had been present for
10-15 days. Eight weeks previously, she had been given a second
dose of recombinant hepatitis B vaccine (Recombivax HB, Pasteur
Mérieux, MSD). On admission, the results of analytical
tests were: white blood cell count 4.9x109/L,
hemoglobin 13.8 g/dL, platelet count 4x109/L;
prothrombin and active partial thromboplastin time normal, as were
assays of biochemistry, C3, C4, rheumatoid factor, reactive C
protein, immunoglobulins and protein electrophoresis. Antinuclear,
antinative DNA, antimuscle flat and antimitochondrial antibodies
were absent. Serological assays for hepatitis C virus, hepatitis A
virus, cytomegalovirus, herpes simplex virus, parvovirus B19,
human immunodeficiency virus, rubella virus, Ebstein-Barr virus
and Toxoplasma were negative, antiHBs antibodies being positive
(>10.000). Direct antiglobulin test was negative, assay for IgG
and IgM antiplatelet antibodies was positive. Abdominal
ultrasonography was normal. Bone marrow aspirate showed
megakaryocytic hyperplasia. Oral corticosteroid treatment
(prednisone 2 mg/k/day) was started. After seven weeks of
treatment, the platelet count had risen to 267x109/L,
and the dose of prednisone was gradually reduced. Six months after
the end of treatment, the platelet count remained normal.
Very few cases of thrombocytopenia associated with recombinant
hepatitis B vaccine have been described. In our patient, the
disorder occurred eight weeks after administering the second dose
of vaccine, as in other published cases.4,5 Response to
treatment was slow - it took seven weeks for the platelet count to
rise. This is not in agreement with the hypothesis of Ronchi et
al. in which the shortest latency time is associated with the
lowest platelet count and longest duration of
thrombocytopenia.2 Treatment with high doses of
corticosteroid seems to be effective to rise the platelet count in
most of the cases, although in several reports was necessary
therapy for long time. The relation between the use of recombinant
hepatitis B vaccine and thrombocytopenic purpura is difficult to
demonstrate, but they may be associated when there is no other
known cause and the latency time is appropriate. Few reports about
this have been published. However, we consider that vaccines,
included recombinant hepatitis B vaccine, and thrombocytopenic
purpura is an association that can not be forgotten.
