Diagnostic Considerations

Other problems to be considered in the differential diagnosis include the following:

Pseudothrombocytopenia (platelet clumping in the presence of ethylenediaminetetraacetic acid [EDTA])
Liver disease
Myelodysplasia
Lymphoproliferative, autoimmune, or infectious diseases
Pregnancy-associated thrombocytopenia
Drug-induced immune thrombocytopenia (alcohol, heparin, quinine/quinidine, sulfonamides, vaccines ^[7])
Infection/sepsis (eg, from hepatitis C virus, human immunodeficiency virus, cytomegalovirus, Epstein–Barr virus, severe acute respiratory syndrome coronavirus‐2 [SARS‐CoV‐2] ^[8])
Acute leukemia
Myelodysplastic syndrome
Malignancy
Megaloblastic anemia
Isoimmune neonatal purpura
Transfusion
Factitious

Immune thrombocytopenia and COVID-19

Mild thrombocytopenia has been reported in approximately 5–10% of patients with symptomatic COVID-19; rarely, severe thrombocytopenia may occur.^{[8, 9, 10]}Case reports of thrombocytopenia following COVID-19 vaccination have also been reported.^{[11, 12]}

In addition, vaccine-induced immune thrombotic thrombocytopenia (VITT)—a novel clinical syndrome with striking similarities to heparin-induced thrombocytopenia but in the absence of heparin exposure—may occur 5-30 days after vaccination with a viral vector–based COVID-19 vaccine. These patients present with mild to severe thrombocytopenia; thrombosis at uncommon sites, including cerebral venous sinus thrombosis and splanchnic venous thrombosis; and positive antibodies against platelet factor 4.^{[13, 14, 15]}VITT is extremely rare. As of May 2021, the estimated incidence was approximately 7-10 cases per million individuals with the AstraZeneca vaccine and approximately 3.2 cases per million with the Johnson & Johnson (Janssen) vaccine.^[13]

Differential Diagnoses

Disseminated Intravascular Coagulation
Rapid HIV Testing
Thrombotic Thrombocytopenic Purpura (TTP)

Workup

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