Main Article Content

Giuseppe Auteri
Simona Paglia
Camilla Mazzoni
Mattia Biondo
Marta Venturi
Andre Davide Romagnoli
Daniela Bartoletti
Michele Cavo
Nicola Vianelli
Francesca Palandri


Immune Thrombocytopenia, COVID19, vaccine, SARS-CoV-2



Several infections and vaccinations can provoke immune thrombocytopenia (ITP) onset or relapse. Information on ITP epidemiology and management during the Covid19 pandemic is scarce.

In a large monocenter ITP cohort, we assessed incidence of and risk factors for: 1) ITP onset/relapse after Covid19 vaccination/ infection; 2) Covid19 infection.


Information on date/type of anti-Covid19 vaccine, platelet count before and within 30 days from vaccine and date/grade of Covid19, was collected via phone call or during hematological visits.

ITP relapse was defined as a drop in PLT count within 30 days from vaccination, compared to PLT count before vaccination that required a rescue therapy OR a dose increase of an ongoing therapy OR a PLT count <30 x109/L with ≥20% decrease from baseline.


Between February 2020 and January 2022, 60 new ITP diagnosis were observed (30% related to Covid19 infection or vaccination). Younger and older age were associated to higher probability of ITP related to Covid19 infection (p=0.02) and vaccination (p=0.04), respectively. Compared to Covid19-unrelated ITP, Infection- and vaccine-related ITP had lower response rates (p=0.03) and required more prolonged therapy (p=0.04), respectively.

Among the 382 patients with known ITP at pandemic start, 18.1% relapsed; relapse was attributed to Covid19 infection/vaccine in 52.2% of the cases. The risk of relapse was higher in patients with active disease (p<0.001) and previous vaccine-related relapse (p=0.006).

Overall, 18.3% of ITP patients acquired Covid19 (severe in 9.9%); risk was higher in unvaccinated patients (p<0.001).


All ITP patients should receive ≥1 vaccine dose and laboratory follow-up after vaccination, with case-by-case evaluation of completion of vaccine program if vaccine-related ITP onset/relapse, and with tempestive initiation of antiviral therapy in unvaccinated patients.


Download data is not yet available.

Abstract 514
PDF Downloads 522
HTML Downloads 167


1 Cyranoski D. New virus identified as likely cause of mystery illness in China. Nature. 2020. doi:10.1038/d41586-020-00020-9.
2 Capobianchi MR, Rueca M, Messina F, Giombini E, Carletti F, Colavita F, Castilletti C, Lalle E, Bordi L, Vairo F, Nicastri E, Ippolito G, Gruber CEM, Bartolini B. Molecular characterization of SARS-CoV-2 from the first case of COVID-19 in Italy. Clin Microbiol Infect. 2020;26:954–56.
3 Hu B, Guo H, Zhou P, Shi Z-L. Characteristics of SARS-CoV-2 and COVID-19. Nat Rev Microbiol. 2021;19:141–54.
4 Rahman A, Niloofa R, Jayarajah U, De Mel S, Abeysuriya V, Seneviratne SL. Hematological Abnormalities in COVID-19: A Narrative Review. Am J Trop Med Hyg. 2021;104:1188–1201.
5 Wool GD, Miller JL. The Impact of COVID-19 Disease on Platelets and Coagulation. Pathobiology. 2021;88:15–27.
6 Xu P, Zhou Q, Xu J. Mechanism of thrombocytopenia in COVID-19 patients. Ann Hematol. 2020;99:1205–8.
7 Zhu Y, Zhang J, Li Y, Liu F, Zhou Q, Peng Z. Association between thrombocytopenia and 180-day prognosis of COVID-19 patients in intensive care units: A two-center observational study. PLoS One. 2021;16:e0248671.
8 Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold DM, Bussel JB, Cines DB, Chong BH, Cooper N, Godeau B, Lechner K, Mazzucconi MG, McMillan R, Sanz MA, Imbach P, Blanchette V, Kühne T, Ruggeri M, George JN. 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.
9 Perricone C, Ceccarelli F, Nesher G, Borella E, Odeh Q, Conti F, Shoenfeld Y, Valesini G. Immune thrombocytopenic purpura (ITP) associated with vaccinations: a review of reported cases. Immunol Res. 2014;60:226–35.
10 Provan D, Arnold DM, Bussel JB, Chong BH, Cooper N, Gernsheimer T, Ghanima W, Godeau B, González-López TJ, Grainger J, Hou M, Kruse C, McDonald V, Michel M, Newland AC, Pavord S, Rodeghiero F, Scully M, Tomiyama Y, Wong RS, Zaja F, Kuter DJ. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv. 2019;3:3780–3817.
11 Neunert C, Terrell DR, Arnold DM, Buchanan G, Cines DB, Cooper N, Cuker A, Despotovic JM, George JN, Grace RF, Kühne T, Kuter DJ, Lim W, McCrae KR, Pruitt B, Shimanek H, Vesely SK. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019;3:3829–66.
12 COVID-19 and ITP - [Internet]. Last accessed date: 2022 Nov 11. Available from:
13 Rodeghiero F, Cantoni S, Carli G, Carpenedo M, Carrai V, Chiurazzi F, De Stefano V, Santoro C, Siragusa S, Zaja F, Vianelli N. Practical Recommendations for the Management of Patients with ITP During the COVID-19 Pandemic. Mediterr J Hematol Infect Dis. 2021;13:e2021032.
14 Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, Perez JL, Pérez Marc G, Moreira ED, Zerbini C, Bailey R, Swanson KA, Roychoudhury S, Koury K, Li P, Kalina WV, Cooper D, Frenck RW, Hammitt LL, Türeci Ö, Nell H, Schaefer A, Ünal S, Tresnan DB, Mather S, Dormitzer PR, Şahin U, Jansen KU, Gruber WC, C4591001 Clinical Trial Group. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020;383:2603–15.
15 Baden LR, El Sahly HM, Essink B, Kotloff K, Frey S, Novak R, Diemert D, Spector SA, Rouphael N, Creech CB, McGettigan J, Khetan S, Segall N, Solis J, Brosz A, Fierro C, Schwartz H, Neuzil K, Corey L, Gilbert P, Janes H, Follmann D, Marovich M, Mascola J, Polakowski L, Ledgerwood J, Graham BS, Bennett H, Pajon R, Knightly C, Leav B, Deng W, Zhou H, Han S, Ivarsson M, Miller J, Zaks T, COVE Study Group. Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine. N Engl J Med. 2021;384:403–16.
16 Emary KRW, Golubchik T, Aley PK, Ariani CV, Angus B, Bibi S, Blane B, Bonsall D, Cicconi P, Charlton S, Clutterbuck EA, Collins AM, Cox T, Darton TC, Dold C, Douglas AD, Duncan CJA, Ewer KJ, Flaxman AL, Faust SN, Ferreira DM, Feng S, Finn A, Folegatti PM, Fuskova M, Galiza E, Goodman AL, Green CM, Green CA, Greenland M, Hallis B, Heath PT, Hay J, Hill HC, Jenkin D, Kerridge S, Lazarus R, Libri V, Lillie PJ, Ludden C, Marchevsky NG, Minassian AM, McGregor AC, Mujadidi YF, Phillips DJ, Plested E, Pollock KM, Robinson H, Smith A, Song R, Snape MD, Sutherland RK, Thomson EC, Toshner M, Turner DPJ, Vekemans J, Villafana TL, Williams CJ, Hill AVS, Lambe T, Gilbert SC, Voysey M, Ramasamy MN, Pollard AJ, COVID-19 Genomics UK consortium, AMPHEUS Project, Oxford COVID-19 Vaccine Trial Group. Efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine against SARS-CoV-2 variant of concern 202012/01 (B.1.1.7): an exploratory analysis of a randomised controlled trial. Lancet. 2021;397:1351–62.
17 Sadoff J, Gray G, Vandebosch A, Cárdenas V, Shukarev G, Grinsztejn B, Goepfert PA, Truyers C, Fennema H, Spiessens B, Offergeld K, Scheper G, Taylor KL, Robb ML, Treanor J, Barouch DH, Stoddard J, Ryser MF, Marovich MA, Neuzil KM, Corey L, Cauwenberghs N, Tanner T, Hardt K, Ruiz-Guiñazú J, Le Gars M, Schuitemaker H, Van Hoof J, Struyf F, Douoguih M, ENSEMBLE Study Group. Safety and Efficacy of Single-Dose Ad26.COV2.S Vaccine against Covid-19. N Engl J Med. 2021;384:2187–2201.
18 Miller E, Waight P, Farrington CP, Andrews N, Stowe J, Taylor B. Idiopathic thrombocytopenic purpura and MMR vaccine. Arch Dis Child. 2001;84:227–29.
19 Moulis G, Crickx E, Thomas L, Massy N, Mahévas M, Valnet-Rabier M-B, Atzenhoffer M, Michel M, Godeau B, Bagheri H, Salvo F. De novo and relapsed immune thrombocytopenia after COVID-19 vaccines: results of French safety monitoring. Blood. 2022;139:2561–65.
20 Lee E-J, Beltrami-Moreira M, Al-Samkari H, Cuker A, DiRaimo J, Gernsheimer T, Kruse A, Kessler C, Kruse C, Leavitt AD, Lee AI, Liebman HA, Newland AC, Ray AE, Tarantino MD, Thachil J, Kuter DJ, Cines DB, Bussel JB. SARS-CoV-2 vaccination and ITP in patients with de novo or preexisting ITP. Blood. 2022;139:1564–74.
21 Visser C, Swinkels M, van Werkhoven ED, Croles FN, Noordzij-Nooteboom HS, Eefting M, Last-Koopmans SM, Idink C, Westerweel PE, Santbergen B, Jobse PA, Baboe F, RECOVAC-IR Consortium, Te Boekhorst PAW, Leebeek FWG, Levin M-D, Kruip MJHA, Jansen AJG. COVID-19 vaccination in patients with immune thrombocytopenia. Blood Adv. 2022;6:1637–44.
22 Kuter DJ. Exacerbation of immune thrombocytopenia following COVID-19 vaccination. Br J Haematol. 2021;195:365–70.
23 Shah SRA, Dolkar S, Mathew J, Vishnu P. COVID-19 vaccination associated severe immune thrombocytopenia. Exp Hematol Oncol. 2021;10:42.
24 Tsao HS, Chason HM, Fearon DM. Immune Thrombocytopenia (ITP) in a Pediatric Patient Positive for SARS-CoV-2. Pediatrics. 2020;146:e20201419.
25 Jawed M, Khalid A, Rubin M, Shafiq R, Cemalovic N. Acute Immune Thrombocytopenia (ITP) Following COVID-19 Vaccination in a Patient With Previously Stable ITP. Open Forum Infect Dis. 2021;8:ofab343.
26 Santhosh S, Malik B, Kalantary A, Kunadi A. Immune Thrombocytopenic Purpura (ITP) Following Natural COVID-19 Infection. Cureus. 2022;14:e26582.
27 Koch M, Fuld S, Middeke JM, Fantana J, von Bonin S, Beyer-Westendorf J. Secondary Immune Thrombocytopenia (ITP) Associated with ChAdOx1 Covid-19 Vaccination - A Case Report. TH Open. 2021;5:e315–18.
28 Al-Ahmad M, Al Rasheed M, Shalaby N, Rodriguez-Bouza T, Altourah L. Immune Thrombocytopenia (ITP): Relapse Versus de novo After COVID-19 Vaccination. Clin Appl Thromb Hemost. 2022;28:10760296211073920.
29 Alonso-Beato R, Morales-Ortega A, Fernández FJD la H, Morón AIP, Ríos-Fernández R, Rubio JLC, Centeno NO. Immune thrombocytopenia and COVID-19: Case report and review of literature. Lupus. 2021;30:1515–21.
30 Matsumura A, Katsuki K, Akimoto M, Sakuma T, Nakajima Y, Miyazaki T, Fujisawa S, Nakajima H. [Immune thrombocytopenia after BNT162b2 mRNA COVID-19 vaccination]. Rinsho Ketsueki. 2021;62:1639–42.
31 Serrano C, Español I, Cascales A, Moraleda JM. Frequently Relapsing Post-COVID-19 Immune Thrombocytopenia. SN Compr Clin Med. 2021;3:2389–92.
32 Ashraf S, Alsharedi M. COVID-19 induced immune thrombocytopenic purpura: case report. Stem Cell Investig. 2021;8:14.
33 Fujita M, Ureshino H, Sugihara A, Nishioka A, Kimura S. Immune Thrombocytopenia Exacerbation After COVID-19 Vaccination in a Young Woman. Cureus. 2021;13:e17942.
34 Chen Y, Xu Z, Wang P, Li X-M, Shuai Z-W, Ye D-Q, Pan H-F. New-onset autoimmune phenomena post-COVID-19 vaccination. Immunology. 2022;165:386–401.
35 Infografica web - Dati della Sorveglianza integrata COVID-19 in Italia [Internet]. Last accessed date: 2022 Dec 5. Available from:
36 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.
37 Moynihan R, Sanders S, Michaleff ZA, Scott AM, Clark J, To EJ, Jones M, Kitchener E, Fox M, Johansson M, Lang E, Duggan A, Scott I, Albarqouni L. Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review. BMJ Open. 2021;11:e045343.
38 De Stefano V, Marchetti M, Rossi E, Ruggeri M, Zaja F, Santoro C, Barcellini W, Carpenedo M, Palandri F, Risitano A, Vianelli N. Piastrinopenia Immune e vaccinazione anti-SARS-CoV-2: raccomandazioni GIMEMA - SIE - SISET. 2021.Available from:
39 Welsh KJ, Baumblatt J, Chege W, Goud R, Nair N. Thrombocytopenia including immune thrombocytopenia after receipt of mRNA COVID-19 vaccines reported to the Vaccine Adverse Event Reporting System (VAERS). Vaccine. 2021;39:3329–32.
40 Tobolowsky FA, Waltenburg MA, Moritz ED, Haile M, DaSilva JC, Schuh AJ, Thornburg NJ, Westbrook A, McKay SL, LaVoie SP, Folster JM, Harcourt JL, Tamin A, Stumpf MM, Mills L, Freeman B, Lester S, Beshearse E, Lecy KD, Brown LG, Fajardo G, Negley J, McDonald LC, Kutty PK, Brown AC, CDC Infection Prevention and Control Team. Longitudinal serologic and viral testing post-SARS-CoV-2 infection and post-receipt of mRNA COVID-19 vaccine in a nursing home cohort-Georgia, October 2020‒April 2021. PLoS One. 2022;17:e0275718.
41 Portuguese AJ, Sunga C, Kruse-Jarres R, Gernsheimer T, Abkowitz J. Autoimmune- and complement-mediated hematologic condition recrudescence following SARS-CoV-2 vaccination. Blood Adv. 2021;5:2794–98.
42 Boettler T, Csernalabics B, Salié H, Luxenburger H, Wischer L, Salimi Alizei E, Zoldan K, Krimmel L, Bronsert P, Schwabenland M, Prinz M, Mogler C, Neumann-Haefelin C, Thimme R, Hofmann M, Bengsch B. SARS-CoV-2 vaccination can elicit a CD8 T-cell dominant hepatitis. J Hepatol. 2022;77:653–59.
43 Chee YJ, Liew H, Hoi WH, Lee Y, Lim B, Chin HX, Lai RTR, Koh Y, Tham M, Seow CJ, Quek ZH, Chen AW, Quek TPL, Tan AWK, Dalan R. SARS-CoV-2 mRNA Vaccination and Graves’ Disease: A Report of 12 Cases and Review of the Literature. J Clin Endocrinol Metab. 2022;107:e2324–30.
44 Klomjit N, Alexander MP, Fervenza FC, Zoghby Z, Garg A, Hogan MC, Nasr SH, Minshar MA, Zand L. COVID-19 Vaccination and Glomerulonephritis. Kidney Int Rep. 2021;6:2969–78.
45 Sattui SE, Liew JW, Kennedy K, Sirotich E, Putman M, Moni TT, Akpabio A, Alpízar-Rodríguez D, Berenbaum F, Bulina I, Conway R, Singh AD, Duff E, Durrant KL, Gheita TA, Hill CL, Howard RA, Hoyer BF, Hsieh E, El Kibbi L, Kilian A, Kim AH, Liew DFL, Lo C, Miller B, Mingolla S, Nudel M, Palmerlee CA, Singh JA, Singh N, Ugarte-Gil MF, Wallace J, Young KJ, Bhana S, Costello W, Grainger R, Machado PM, Robinson PC, Sufka P, Wallace ZS, Yazdany J, Harrison C, Larché M, Levine M, Foster G, Thabane L, Rider LG, Hausmann JS, Simard JF, Sparks JA. Early experience of COVID-19 vaccination in adults with systemic rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance Vaccine Survey. RMD Open. 2021;7:e001814.
46 Shoenfeld Y, Agmon-Levin N. “ASIA” - autoimmune/inflammatory syndrome induced by adjuvants. J Autoimmun. 2011;36:4–8.
47 Jara LJ, Vera-Lastra O, Mahroum N, Pineda C, Shoenfeld Y. Autoimmune post-COVID vaccine syndromes: does the spectrum of autoimmune/inflammatory syndrome expand? Clin Rheumatol. 2022;41:1603–9.
48 Breccia M, Piciocchi A, Messina M, Soddu S, De Stefano V, Bellini M, Iurlo A, Martino B, Siragusa S, Albano F, Mora B, Fazi P, Vignetti M, Guglielmelli P, Palandri F. Covid-19 in Philadelphia-negative myeloproliferative neoplasms: a GIMEMA survey on incidence, clinical management and vaccine. Leukemia. 2022;36:2548–50.
49 Pagano L, Salmanton-García J, Marchesi F, Busca A, Corradini P, Hoenigl M, Klimko N, Koehler P, Pagliuca A, Passamonti F, Verga L, Víšek B, Ilhan O, Nadali G, Weinbergerová B, Córdoba-Mascuñano R, Marchetti M, Collins GP, Farina F, Cattaneo C, Cabirta A, Gomes-Silva M, Itri F, van Doesum J, Ledoux M-P, Čerňan M, Jakšić O, Duarte RF, Magliano G, Omrani AS, Fracchiolla NS, Kulasekararaj A, Valković T, Poulsen CB, Machado M, Glenthøj A, Stoma I, Ráčil Z, Piukovics K, Navrátil M, Emarah Z, Sili U, Maertens J, Blennow O, Bergantim R, García-Vidal C, Prezioso L, Guidetti A, Del Principe MI, Popova M, de Jonge N, Ormazabal-Vélez I, Fernández N, Falces-Romero I, Cuccaro A, Meers S, Buquicchio C, Antić D, Al-Khabori M, García-Sanz R, Biernat MM, Tisi MC, Sal E, Rahimli L, Čolović N, Schönlein M, Calbacho M, Tascini C, Miranda-Castillo C, Khanna N, Méndez G-A, Petzer V, Novák J, Besson C, Duléry R, Lamure S, Nucci M, Zambrotta G, Žák P, Seval GC, Bonuomo V, Mayer J, López-García A, Sacchi MV, Booth S, Ciceri F, Oberti M, Salvini M, Izuzquiza M, Nunes-Rodrigues R, Ammatuna E, Obr A, Herbrecht R, Núñez-Martín-Buitrago L, Mancini V, Shwaylia H, Sciumè M, Essame J, Nygaard M, Batinić J, Gonzaga Y, Regalado-Artamendi I, Karlsson LK, Shapetska M, Hanakova M, El-Ashwah S, Borbényi Z, Çolak GM, Nordlander A, Dragonetti G, Maraglino AME, Rinaldi A, De Ramón-Sánchez C, Cornely OA, EPICOVIDEHA working group. COVID-19 infection in adult patients with hematological malignancies: a European Hematology Association Survey (EPICOVIDEHA). J Hematol Oncol. 2021;14:168.
50 Hyrich KL, Machado PM. Rheumatic disease and COVID-19: epidemiology and outcomes. Nat Rev Rheumatol. 2021;17:71–72.
51 Cordtz R, Lindhardsen J, Soussi BG, Vela J, Uhrenholt L, Westermann R, Kristensen S, Nielsen H, Torp-Pedersen C, Dreyer L. Incidence and severeness of COVID-19 hospitalization in patients with inflammatory rheumatic disease: a nationwide cohort study from Denmark. Rheumatology (Oxford). 2021;60:SI59–67.