Exacerbations or de novo cases of autoimmune cytopenias secondary to COVID-19 infection and vaccines have been frequently reported, whilst the association with aplastic anemia (AA) or pure red cell aplasia (PRCA) is rarer. We describe eight AA patients (6 severe/2 non-severe) diagnosed after a median of 2.3 months from the last dose of anti-SARS-CoV-2 vaccine. All required immunosuppression and about 70% responded at 6 months. By immune-histochemistry, bone marrow samples were negative for Spike protein whilst an abundant anti-IgM, anti-IgG, anti-C3, and anti-C4d immunoreactivity was observed. The comparison with bone marrow samples from AA patients diagnosed before COVID19 pandemics showed increased immunoglobulins and complement deposition in AA patients diagnosed after SARS-CoV-2 vaccine. Literature review showed 6 AA cases developing after SARS-CoV-2 infection and 10 after vaccine. A clear causative link is difficult to establish, but for the temporal association. Physiopathology seems more associated with a broader autoimmune activation than to a specific anti-Spike attack, although further investigation is needed.
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