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we report severe thrombocytopenia ( i.e. , platelet count < 50  10/l ) ( 15 ) , which developed during or after the course of acute zika virus infection in 7 patients who were admitted to the guadeloupe university hospital , french west indies , during may  august 2016 .
the 7 patients ( 5 women and 2 men , mean age 43 years , range 1574 years ) had petechial purpura in the lower limbs ( table ) .
five of the patients also had additional bleeding signs and symptoms ( gingival bleeding , epistaxis , oral hemorrhagic mucosal blisters , and hematuria ) .
all 7 patients had a typical zika virus infection ( median 5 days , range 218 days ) before diagnosis of thrombocytopenia .
median minimum platelet count was 2  10/l ( range 1  10/l17  10/l ) .
* denv , dengue virus ; ivig , intravenous immune globulins ; min , minimum ; plas , plasma ; pt , patient ; unk , unknown . 
none had recently received a new medication or vaccination or had traveled to an area to which malaria is endemic .
no underlying conditions , such as autoimmune or lymphoproliferative disorders , were known or identified for any patient .
serologic test results for hiv and hepatitis b virus were negative for all 7 patients .
two of 7 patients had positive serologic results for hepatitis c virus ; these 2 patients had negative results for hepatitis c virus rna in plasma .
serologic test results ruled out diagnoses of acute leptospirosis , cytomegalovirus infection , and epstein - barr virus infection for all 7 patients .
six of 7 patients showed negative results for parvovirus b19 infection ( 1 patient was not tested ) .
we did not test patients for chikungunya virus because this virus had not been detected in guadeloupe since january 2015 .
we tested patients for infection with zika virus and dengue virus ( denv ) by using reverse transcription pcr ( rt - pcr ) for urine samples < 6 days of onset of purpura .
results of rt - pcr were positive for zika virus and negative for denv for all patients .
in addition , results of serum tests for denv nonstructural protein 1 were negative for all patients .
a diagnosis of acute immune mediated thrombocytopenia ( itp ) was made for all 7 patients . because of thrombocytopenia severity , all patients received steroid therapy with either prednisone or methylprednisolone at an initial dosage of 12 mg / kg / day .
, platelet counts returned to reference ranges < 15 days after treatment initiation for all patients .
we provide additional information on the atypical clinical course that was observed for 3 of the patients .
she had been treated for primary itp during 20042007 with steroids and ivig , followed by vinblastine and danazol , and eventually splenectomy , which was curative . in 2014 ,
an acute chikungunya virus infection caused a relapse of itp , which fully responded to a short - course steroid treatment . during 20142016 , she remained asymptomatic and had a platelet count > 100  10/l . in may 2016
the patient had petechiae in the upper and lower limbs and a platelet count of 17  10/l .
her clinical course rapidly became favorable after steroid therapy , and she had a platelet count of 172  10/l by day 5 of steroid therapy .
patient 2 responded only partially to steroids and ivig and had a maximum platelet count of 92  10/l at day 14 after treatment initiation .
while she was underdoing tapering of steroid treatment , palate petechiae appeared on day 39 ( platelet count 9  10/l ) .
prednisone ( 1 mg / kg / day ) was given for 10 days and was followed by a sustained recovery of the platelet count .
patient 7 had severe hemorrhagic manifestations ( gross hematuria and oral hemorrhagic blisters ) and platelet count of 1  10/l .
he was hospitalized in an intensive care unit and received steroid therapy , ivig , and platelet transfusion .
the patient showed a full response to treatment ( platelet count 169  10/l at day 7 of treatment ) .
from the beginning of the current zika outbreak in the americas to november 2016 , nine case - patients with severe zika virus  associated thrombocytopenia have been reported , 1 in suriname ( 10 ) , 4 in colombia ( 11,12 ) , 2 in puerto rico ( 13 ) , and 2 in martinique ( 14 ) .
we report information for these 9 case - patients and the 7 patients we analyzed in guadeloupe ( table ) .
first , all had severe and profound thrombocytopenia ( platelet counts < 20  10/l ) .
second , probably as a consequence of thrombocytopenia , hemorrhagic manifestations developed in all but 1 patient . third , thrombocytopenia was present shortly after acute zika virus infection , and zika virus rna was still detected in urine from 11 of the 12 patients for whom rt - pcr for zika virus was performed .
overall , despite the severity of thrombocytopenia , the outcome was generally favorable after conventional steroid treatment with or without ivig . among the 4 patients who died , only 1 patient had isolated thrombocytopenia ; this patient died of hemorrhagic complications ( 13 ) .
the other 3 patients had various systemic signs and symptoms and thrombocytopenia ; thrombocytopenia was the direct cause of death for only 1 patient ( 11 ) .
for the 7 patients in guadeloupe , we were able to exclude all other main causes of isolated severe thrombocytopenia , especially denv infection . because all 7 patients still had a positive rt - pcr result for zika virus in urine when thrombocytopenia was diagnosed
as reported for other viruses , zika virus  associated itp might result from stimulation of the immune system , which usually decreases after clearance of viral replication .
the mechanism of thrombocytopenia was probably different in patients 1 and 16 ( 12 ) , in whom thrombocytopenia appeared as a relapse of previous itp . in conclusion , thrombocytopenia is a rare complication of zika virus infection .
therefore , zika virus should be included in the list of viruses that might trigger immune - mediated severe thrombocytopenia .
severe thrombocytopenia during or after the course of zika virus infection has been rarely reported . 
 we report 7 cases of severe thrombocytopenia and hemorrhagic signs and symptoms in guadeloupe after infection with this virus . 
 clinical course and laboratory findings strongly suggest a causal link between zika virus infection and immune - mediated thrombocytopenia .