A case of severe aplastic anaemia after SARS-CoV-2 vaccination
A case of severe aplastic anaemia after SARS-CoV-2 vaccination
There is increasing awareness about the possible relationship between severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccines and the development of haematological diseases, including autoimmune cytopenias (AICs) and complement-mediated diseases. Specifically, the development or recrudescence of autoimmune haemolytic anaemia,1, 2 immune thrombocytopenia purpura3, 4 and paroxysmal nocturnal haemoglobinuria (PNH)5, 6 have been described secondarily to coronavirus disease 2019 (COVID-19) vaccines, regardless of the type. It has been reported that vaccines other than anti-SARS-CoV-2 could trigger AICs, as well as complement activation, although the matter is highly debated.7, 8 Only few data have been reported regarding aplastic anaemia (AA) that is characterised by the premature death of bone marrow precursors due to a T-cell mediated immune attack. AA may be primary or secondary to several triggers, and a number of cases developing or relapsing after vaccine for hepatitis B virus (HBV), H1N1 influenza, varicella-zoster virus have been described.9, 15 Here we report the first case of acquired AA developing after the administration of SARS-CoV-2 Pfizer-Biontech mRNA vaccine.
In April 2021 a 76-year-old male was admitted to a local hospital because of the sudden onset of haematomas and epistaxis. His personal past and family medical history were unremarkable. The patient had never had symptoms of cytopenia (i.e. pallor, fatigue, jaundice, bleeding, or harmful/frequent infections), and blood counts from ˜1 year before presentation were within the normal range. He had completed the SARS-CoV-2 Pfizer-Biontech vaccination schedule in March (Fig 1). At 1 month after the second dose, he developed asthenia and muco-cutaneous bleeding. At admission, laboratory tests found severe thrombocytopenia [platelet count (PLT) 3 × 109/l], confirmed in sodium-citrate, leucopenia (white blood cells 3.7 × 109/l) with severe neutropenia [absolute neutrophil count (ANC) 0·46 × 109/l), and mild normocytic anaemia [haemoglobin (Hb) 112 g/l]. Haemolytic markers were normal except for a slight lactate dehydrogenase increase (1·1 × upper limit of normal). Reticulocytes were low (38 × 109/l), and serum erythropoietin levels increased (308 mu/ml). Vitamins and iron status, coagulation tests, serum electrophoresis, and total immunoglobulins (Igs) were within the normal ranges. Blood smear showed no schistocytes nor blasts. Serology for HBV, human immunodeficiency virus, hepatitis C virus and Epstein–Barr virus was negative, whilst cytomegalovirus (CMV) and parvovirus B-19 IgG were positive (DNA negative). Autoimmune tests were all negative, including direct anti-globulin test (DAT), anti-nuclear antibodies (ANA), extractable nuclear antigen (ENA), p- and c-anti-neutrophil cytoplasmic antibodies (p-ANCA, c-ANCA). Bone marrow aspirate and biopsy showed 10% cellularity in absence of blasts or dysplastic features, and normal cytogenetics. Flow cytometry revealed the presence of a small PNH clone of 0·6% on granulocytes and 0·03% on erythrocytes. The diagnosis of severe AA (SAA) according to Camitta criteria was established, and the patient started on steroids (prednisone 1 mg/kg/day) and platelets transfusions with no response. Due to worsening pancytopenia (Hb 88 g/l, ANC 0.9 × 109/l, PLT 10 × 109/l) he was then referred to our Centre (May 2021) and treated with immunosuppressive therapy (IST, cyclosporin 3 mg/kg/day + rabbit anti-thymocyte globulin, ATG). At 15 days after ATG, the patient developed fever and severe right knee arthritis interpreted as serum sickness and managed at first with high-dose steroids. Thereafter, synovial liquid culture turned positive for Pseudomonas aeruginosa, and CMV reactivation occurred, requiring intravenous antibiotic and anti-viral therapy, with progressive resolution of the clinical picture. At last follow-up the patient was still severely pancytopenic and transfusion-dependent (Hb 82 g/l, ANC 0·58 × 109/l, PLT 18 × 109/l, after transfusion).
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