Background and importance Cases of thrombocytopenia, including immune thrombocytopenia (ITP), have been reported after receiving Vaxzevria, typically within the first 4 weeks after vaccination.

Very rarely, these events presented with very low platelet levels (<20×10⁹/L) and/or were associated with bleeding.

Intravenous immunoglobulins and dexamethasone (high doses) are used to treat IPT secondary to COVID-19 vaccine.

Aim and objectives To describe a case of severe ITP secondary to COVID-19 vaccine successfully treated with eltrombopag.

Material and methods A 60-year-old male, with a clinical history of hypertension, consulted to the emergency department for spontaneous appearance of ecchymosis and petechiae of 10–12 days of evolution.

To highlight, he had received a first dose of Vaxzevria on 27 May 2021.

Physical examination revealed diffuse haematomas on the chest and arms. No haematuria, gingivorrhagia or active digestive bleeding were observed.

As the platelet count was 6×10⁹/L and no other relevant alterations were observed, it was oriented as an acute ITP possibly related to Vaxzevria.

Corticosteroid treatment was started with methylprednisolone 1 mg/kg/day. The serological study and immune profile were negative. A thoracoabdominal computed tomography scan ruled out a neoproliferative process.

Although the patient remained stable, he required a bolus of dexamethasone 40 mg/day for 4 days in the absence of a platelet response to methylprednisolone. Despite this, plaquetopenia persisted, so a bone marrow aspirate was performed. The study confirmed the presence of megakaryocytes, which indicated the existence of peripheral plaquetopenia. Therefore, treatment with eltrombopag was started.

Results Treatment with eltrombopag 50 mg/day was started on 22 July 2021, with a platelet count of 5×10⁹/L. After 1 week the platelet count was 4×10⁹/L so the dose was raised to 75 mg/day. Five days after increasing the dose, the platelet count rose to 21×10⁹/L. Two days after it was 41×10⁹/L so the patient was discharged with outpatient monitoring. On 14 October 2021 the platelet count was 101×10⁹/L.

Conclusion and relevance Mild and transient thrombocytopenia is a common adverse event described for Vaxzevria. Cases presented with very low platelet levels are very rare. Nevertheless, the benefit of vaccination continues to outweigh the risks.

We describe a severe case of ITP secondary to COVID-19 vaccine successfully treated with eltrombopag after failure of systemic corticosteroids.

Conflict of interest No conflict of interest