Serious adverse effects following MMR vaccination include Autism, Inflammatory Bowel Disease, Guillain Barre Syndrome, Thrombocytopenia, hypersensitivity reaction. Incidence of thrombocytopenia following MMR Vaccination is 0.5 to 33 cases / 1 million doses(1). In our case patient presented with bleeding tendency following MMR vaccination after 15 days. The sixteen months-old-male child came with petechial rash and spontaneous bruising over forehead and buttocks of 1 day duration and epistaxis of 15 minutes duration. The patient had received MMR vaccine 15 days prior with us. It was not followed by maculopapular rash, fever or hypersensitivity reaction. There was no history of similar episode following measles vaccine. On general examination vitals were within normal limits, petechial rash all over body ecchymosis over right side of forehead and buttocks was noticed. Patient also had active nasal bleeding which was managed with nasal packing with adrenaline. Investigations revealed Hb = 11.8 gm%, Total Leucocyte count = 9200/cumm, Differential Leucocyte count = N-33%, L-60%, E-04%, M-03%, B-00%, platelet count of 2000/cumm. In view of active bleeding and Platelet count of 2000/cumm patient was transfused with one unit of single donor platelet immediately. No fresh lesions and active bleeding from any other site was seen after the episode. On the 2nd day the platelet count rose to 1.93 lakhs/cumm. Color of bruises changed from purple to brown on 4th day and platelet count on the same day was 87000/cumm. Patient was discharged from hospital as clinical condition was stable. Patient was followed after 7 days and platelet count was repeated which showed a rise to 4 lakhs/cumm without any active intervention. Clinical diagnosis of thrombocytopenia following MMR vaccination was made considering the fact that patient received MMR vaccine 15 days prior to the episode. Thrombocytopenia caused by MMR vaccine is benign and clinically apparent within two months of immunization and occurs at a rate of one per ten lakhs doses. Based on case reports the risk of vaccine associated thrombocytopenia may be higher for persons who have previously experienced thrombocytopenia especially in temporal association with earlier MMR immunization. No reports of thrombo-cytopenia associated with receipt of MMR vaccine have resulted in death(2). Vaccine adverse reporting system (VAERS), FDA noted that thrombocytopenia following immunization with measles containing vaccine was more severe than previously perceived. Investigators in Finland had reported that 30% of children with thrombo-cytopenia had detectable anti-IIb-IIIa platelet antibodies. FDA’s laboratory of pediatric and respiratory diseases imitated a research study to identify vaccine antigens that might be responsible for inducing antiplatelet anti-bodies, indicating that they may be at risk for episodes of immune thrombocytopenia when re-exposed to any vaccine that contain cross reacting antigen.Thrombocytopenia after DTP immunization is less frequent and usually has shorter interval of onset than after MMR. (mean 7 days vs. 16 days)(3).

There is an increase risk of ITP within 6 weeks of MMR immunization. However, the attributable risk of ITP within 6 weeks after MMR vaccination is low(4). In our case thrombocytopenia developed after 15 days of MMR vaccination. Immunological studies could not be carried out. The decision to immunize children should be based on benefit of protection against MMR in comparison with risks of recurrence of thrombocytopenia after immunization.

S.S. Kashyape,
P.S. Kashyape,
Shree Medical Research Center,
Kashyape Children Hospital, Nasik, Maharashtra, India.
E-mail: [email protected]