1
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Vayne C, Rollin J, Clare R, Daka M, Atsouawe M, Guéry EA, Cauchie P, Cordonnier C, Cuisenier P, De Maistre E, Donnard M, Drillaud N, Faille D, Galinat H, Gouin-Thibault I, Lemoine S, Mourey G, Mullier F, Siguret V, Susen S, Godon A, Nazy I, Gruel Y, Pouplard C. The use of 1E12, a monoclonal anti-platelet factor 4 antibody, to improve the diagnosis of vaccine-induced immune thrombotic thrombocytopenia. J Thromb Haemost 2024; 22:2306-2315. [PMID: 38762021 DOI: 10.1016/j.jtha.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/04/2024] [Accepted: 05/02/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a complication of adenoviral-based vaccine against SARS-CoV-2 due to prothrombotic immunoglobulin (Ig) G antibodies to platelet factor 4 (PF4) and may be difficult to distinguish from heparin-induced thrombocytopenia (HIT) in patients treated with heparin. OBJECTIVES We assessed the usefulness of competitive anti-PF4 enzyme immunoassays (EIAs) in this context. METHODS The ability of F(ab')2 fragments of 1E12, 1C12, and 2E1, 3 monoclonal anti-PF4 antibodies, to inhibit the binding of human VITT or HIT antibodies to PF4 was evaluated using EIAs. Alanine-scanning mutagenesis was performed to define the amino acids involved in the interactions between the monoclonal antibodies and PF4. RESULTS A strong inhibition of VITT IgG binding to PF4 was measured with 1E12 (median inhibition, 93%; n = 8), whereas it had no effect on the binding of HIT antibodies (median, 6%; n = 8). In contrast, 1C12 and 2E1 inhibited VITT (median, 74% and 76%, respectively) and HIT antibodies (median, 68% and 53%, respectively) binding to PF4. When a competitive anti-PF4 EIA was performed with 1E12 for 19 additional VITT samples, it strongly inhibited IgG binding to PF4, except for 1 patient, who had actually developed HIT according to the clinical history. Epitope mapping showed that 1E12 interacts with 5 key amino acids on PF4, of which 4 are also required for the binding of human VITT antibodies, thus explaining the competitive inhibition. CONCLUSION A simple competitive anti-PF4 EIA with 1E12 could help confirm VITT diagnosis and distinguish it from HIT in patients when both diagnoses are possible.
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MESH Headings
- Humans
- Platelet Factor 4/immunology
- Heparin/adverse effects
- Heparin/immunology
- Antibodies, Monoclonal/immunology
- Antibodies, Monoclonal/adverse effects
- COVID-19 Vaccines/adverse effects
- COVID-19 Vaccines/immunology
- Immunoglobulin G/blood
- Immunoglobulin G/immunology
- Predictive Value of Tests
- Anticoagulants/adverse effects
- Anticoagulants/immunology
- COVID-19/immunology
- COVID-19/prevention & control
- COVID-19/diagnosis
- Immunoglobulin Fab Fragments/immunology
- Immunoglobulin Fab Fragments/adverse effects
- Protein Binding
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/chemically induced
- SARS-CoV-2/immunology
- Binding, Competitive
- Purpura, Thrombotic Thrombocytopenic/immunology
- Purpura, Thrombotic Thrombocytopenic/diagnosis
- Purpura, Thrombotic Thrombocytopenic/blood
- Purpura, Thrombotic Thrombocytopenic/chemically induced
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Affiliation(s)
- Caroline Vayne
- Department of Haemostasis, Regional University Hospital Centre Tours, Tours, France; Institut National de la Santé et de la Recherche Médicale INSERM U1327 ISCHEMIA, Membrane Signalling and Inflammation in Reperfusion Injuries, Université de Tours, Tours, France.
| | - Jérôme Rollin
- Department of Haemostasis, Regional University Hospital Centre Tours, Tours, France; Institut National de la Santé et de la Recherche Médicale INSERM U1327 ISCHEMIA, Membrane Signalling and Inflammation in Reperfusion Injuries, Université de Tours, Tours, France
| | - Rumi Clare
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote Centre for Transfusion Research, Hamilton, Ontario, Canada
| | - Mercy Daka
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote Centre for Transfusion Research, Hamilton, Ontario, Canada
| | - Merveille Atsouawe
- Institut National de la Santé et de la Recherche Médicale INSERM U1327 ISCHEMIA, Membrane Signalling and Inflammation in Reperfusion Injuries, Université de Tours, Tours, France
| | - Eve-Anne Guéry
- Department of Haemostasis, Regional University Hospital Centre Tours, Tours, France
| | - Philippe Cauchie
- Service de Biologie Clinique, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Charlotte Cordonnier
- Inserm, Centre Hospitalier Universitaire Lille, U1172-Lille Neurosciences and Cognition, University of Lille, Lille, France
| | - Pauline Cuisenier
- Stroke Unit, Neurology Department, University Hospital of Grenoble Alpes, Grenoble, France
| | | | - Magali Donnard
- Haemostasis Unit, Limoges University Hospital, Limoges, France
| | - Nicolas Drillaud
- Department of Haemostasis, Nantes University Hospital, Nantes, France
| | - Dorothée Faille
- Département d'Hématologie Biologique, Institut National de la Santé et de la Recherche Médicale U1148, Laboratory for Vascular Translational Science, Centre Hospitalier Universitaire Bichat-Claude Bernard, Paris, France
| | - Hubert Galinat
- Service d'Hématologie Biologique, Centre Hospitalier Régional Universitaire Brest, Brest, France
| | - Isabelle Gouin-Thibault
- Department of Hemostasis, University Hospital of Rennes, Institut National de la Santé et de la Recherche Médicale, Ecole des Hautes Etudes en Santé Publique, Institut de Recherche en Santé, Environnement et Travail, Unité Mixte de Recherche_S 1085, University of Rennes, Rennes, France
| | - Sandrine Lemoine
- Centre Hospitalier Universitaire Angers, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Centre de Recherche en Cancérologie et Immunologie Intégrée Nantes Angers, Laboratoire d'Hématologie, Université d'Angers, Nantes Université, Angers, France
| | - Guillaume Mourey
- Service d'Hémostase, Centre Hospitalier Universitaire Besançon, Besançon, France
| | - François Mullier
- Université Catholique de Louvain Namur, Thrombosis and Hemostasis Center, Université catholique de Louvain, Centre Hospitalier Universitaire, Yvoir, Belgium
| | - Virginie Siguret
- Service d'Hématologie biologique, Hôpital Lariboisière, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche_S1140, Innovative Therapeutics in Haemostasis, University of Paris, Paris, France
| | - Sophie Susen
- Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire Lille, University of Lille, Institut Pasteur de Lille, U1011-Europena Genomic Institute for Diabetes, Lille, France
| | - Alban Godon
- Centre Hospitalier Universitaire Angers, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Centre de Recherche en Cancérologie et Immunologie Intégrée Nantes Angers, Laboratoire d'Hématologie, Université d'Angers, Nantes Université, Angers, France
| | - Ishac Nazy
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote Centre for Transfusion Research, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Yves Gruel
- Department of Haemostasis, Regional University Hospital Centre Tours, Tours, France; Institut National de la Santé et de la Recherche Médicale INSERM U1327 ISCHEMIA, Membrane Signalling and Inflammation in Reperfusion Injuries, Université de Tours, Tours, France
| | - Claire Pouplard
- Department of Haemostasis, Regional University Hospital Centre Tours, Tours, France; Institut National de la Santé et de la Recherche Médicale INSERM U1327 ISCHEMIA, Membrane Signalling and Inflammation in Reperfusion Injuries, Université de Tours, Tours, France
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2
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Meier RT, Porcelijn L, Hofstede-van Egmond S, Henskens YMC, Coutinho JM, Kruip MJHA, Stroobants AK, Zwaginga JJ, van der Bom JG, van der Schoot CE, de Haas M, Kapur R. Laboratory approach for vaccine-induced thrombotic thrombocytopenia diagnosis in the Netherlands. Vox Sang 2024; 119:728-736. [PMID: 38597072 DOI: 10.1111/vox.13633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/19/2024] [Accepted: 03/24/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND AND OBJECTIVES Vaccine-induced thrombotic thrombocytopenia (VITT) is a rare adverse effect characterized by thrombocytopenia and thrombosis occurring after COVID-19 vaccination. VITT pathophysiology is not fully unravelled but shows similarities to heparin-induced thrombocytopenia (HIT). HIT is characterized by the presence of antibodies against platelet factor 4 (PF4)/heparin complex, which can activate platelets in an FcγRIIa-dependent manner, whereas IgG-antibodies directed against PF4 play an important role in VITT. MATERIALS AND METHODS We characterized all clinically suspected VITT cases in the Netherlands from a diagnostic perspective and hypothesized that patients who developed both thrombocytopenia and thrombosis display underlying mechanisms similar to those in HIT. We conducted an anti-PF4 ELISA and a functional PF4-induced platelet activation assay (PIPAA) with and without blocking the platelet-FcγRIIa and found positivity in both tests, suggesting VITT with mechanisms similar to those in VITT. RESULTS We identified 65 patients with both thrombocytopenia and thrombosis among 275 clinically suspected VITT cases. Of these 65 patients, 14 (22%) tested positive for anti-PF4 and PF4-dependent platelet activation. The essential role of platelet-FcγRIIa in VITT with mechanisms similar to those in HIT was evident, as platelet activation was inhibited by an FcγRIIa-blocking antibody in all 14 patients. CONCLUSION Our study shows that only a small proportion of clinically suspected VITT patients with thrombocytopenia and thrombosis have anti-PF4-inducing, FcɣRIIa-dependent platelet activation, suggesting an HIT-like pathophysiology. This leaves the possibility for the presence of another type of pathophysiology ('non-HIT like') leading to VITT. More research on pathophysiology is warranted to improve the diagnostic algorithm and to identify novel therapeutic and preventive strategies.
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Affiliation(s)
- Romy T Meier
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Leendert Porcelijn
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Sanquin, The Netherlands
| | | | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - An K Stroobants
- Department of Clinical Chemistry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap J Zwaginga
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - C Ellen van der Schoot
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Masja de Haas
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Sanquin, The Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rick Kapur
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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3
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Choi PYI, Uzun G, Bakchoul T. Results of an international survey of opinions on the definitions and treatments for heparin-induced thrombocytopenia: communication from the ISTH SSC Subcommittee on Platelet Immunology. J Thromb Haemost 2024; 22:1772-1778. [PMID: 38301999 DOI: 10.1016/j.jtha.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/08/2024] [Accepted: 01/20/2024] [Indexed: 02/03/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is rare, affecting fewer than 1 in 1500 hospital admissions. Despite the increasing adoption of new therapies in HIT, such as direct oral anticoagulants and pooled immunoglobulins, there is limited high-quality evidence to guide clinicians. Numerous uncommon presentations of HIT and HIT-like entities have recently been recognized, and a harmonized approach to their classification is required to study them better. We present the results of an international survey of opinions from experts and practitioners in the field of platelet immunology regarding the role of direct oral anticoagulants in HIT, novel definitions of subclassifications of HIT-like platelet factor 4 immune conditions (spontaneous autoimmune HIT, persistent autoimmune HIT, and treatment-refractory HIT), and the role for intravenous immunoglobulins in the treatment paradigm of HIT and these HIT-like conditions. From 102 survey responses, there was broad acceptance of rivaroxaban (74.5%) and apixaban (73.5%) even before platelet recovery, as well as for intravenous immunoglobulin in the management of spontaneous (85.6%), persistent (83.7%), and treatment-refractory HIT (87.4%). With this mandate for harmonizing terminologies and treatment approaches in special situations without robust clinical data owing to their rarity, we plan to conduct a robust survey, establish international consensus, and draft management guidelines for HIT and platelet factor 4 immune diseases in the near future.
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MESH Headings
- Humans
- Heparin/adverse effects
- Heparin/immunology
- Immunoglobulins, Intravenous/therapeutic use
- Immunoglobulins, Intravenous/adverse effects
- Thrombocytopenia/chemically induced
- Thrombocytopenia/immunology
- Thrombocytopenia/diagnosis
- Anticoagulants/adverse effects
- Platelet Factor 4/immunology
- Surveys and Questionnaires
- Pyrazoles/adverse effects
- Pyrazoles/therapeutic use
- Blood Platelets/immunology
- Blood Platelets/drug effects
- Blood Platelets/metabolism
- Pyridones/adverse effects
- Pyridones/therapeutic use
- Rivaroxaban/adverse effects
- Purpura, Thrombocytopenic, Idiopathic/chemically induced
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Health Care Surveys
- Terminology as Topic
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Affiliation(s)
- Philip Young-Ill Choi
- Haematology Department, the Canberra Hospital, Garran, Canberra, Australian Capital Territory, Australia; John Curtin School of Medical Research, Australian National University, Acton, Canberra, Australian Capital Territory, Australia
| | - Günalp Uzun
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany.
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4
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Warkentin TE. A career in solving clinical-pathological conundrums: Heyde syndrome, anti-platelet factor 4 disorders, and microvascular limb ischemic necrosis. Int J Lab Hematol 2024; 46 Suppl 1:12-26. [PMID: 38432651 DOI: 10.1111/ijlh.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
Hematology is a clinical specialty with strong roots in the laboratory; accordingly, the lab can help solve perplexing clinical problems. This review highlights clinical-pathological conundrums addressed during my 35-year hematology career at McMaster University. Heyde syndrome is the association between aortic stenosis and bleeding gastrointestinal (GI) angiodysplasia where the bleeding is usually cured by aortic valve replacement; the chance reading of a neonatal study showing reversible deficiency of high-molecular-weight (HMW) multimers of von Willebrand factor (vWF) following surgical correction of congenital heart disease provided the key insight that a subtle deficiency of HMW multimers of vWF explains Heyde syndrome. The unusual immunobiology of heparin-induced thrombocytopenia (HIT)-a highly prothrombotic, antibody-mediated, anti-platelet factor 4 (PF4) disorder featuring rapid appearance and then disappearance (seroreversion) of the pathological heparin-dependent platelet-activating antibodies-permitted identification of key clinical features that informed development of a scoring system (4Ts) to aid in HIT diagnosis. Atypical clinical presentations of HIT prompted identification of heparin-independent anti-PF4 antibodies, now recognized as the explanation for vaccine-induced immune thrombotic thrombocytopenia (VITT), as well as VITT-like disorders triggered by adenovirus infection. Another unusual feature of HIT is its strong association with limb ischemia, including limb necrosis secondary to deep-vein/microvascular thrombosis (venous limb gangrene). The remarkable observation that supratherapeutic warfarin anticoagulation predisposes to HIT- and cancer-associated venous limb gangrene provided insight into disturbed procoagulant/anticoagulant balance; these concepts are relevant to microvascular thrombosis in critical illness (symmetrical peripheral gangrene), including a pathophysiological role for proximate "shock liver" (impaired hepatic synthesis of natural anticoagulants).
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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5
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Yamada S, Asakura H. How We Interpret Thrombosis with Thrombocytopenia Syndrome? Int J Mol Sci 2024; 25:4956. [PMID: 38732176 PMCID: PMC11084439 DOI: 10.3390/ijms25094956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Platelets play an important role in hemostasis, and a low platelet count usually increases the risk of bleeding. Conditions in which thrombosis occurs despite low platelet counts are referred to as thrombosis with thrombocytopenia syndrome, including heparin-induced thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia, paroxysmal nocturnal hemoglobinuria, antiphospholipid syndrome, thrombotic microangiopathy (TMA), and disseminated intravascular coagulation. TMA includes thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS), and atypical HUS. Patients with these pathologies present with thrombosis and consumptive thrombocytopenia associated with the activation of platelets and the coagulation system. Treatment varies from disease to disease, and many diseases have direct impacts on mortality and organ prognosis if therapeutic interventions are not promptly implemented. Underlying diseases and the results of physical examinations and general laboratory tests as part of a thorough workup for patients should promptly lead to therapeutic intervention before definitive diagnosis. For some diseases, the diagnosis and initial treatment must proceed in parallel. Utilization of not only laboratory tests but also various scoring systems is important for validating therapeutic interventions based on clinical information.
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Affiliation(s)
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa City 920-8640, Ishikawa, Japan;
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6
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Khan Z, Patel I, Gardner T, Wei X, Cheng M, Vesely MR, Benitez RM, Zimrin AB, Wang L, Finn AV. Recurrent Stent Thrombosis Following Myocardial Infarction Associated With VITT-Like Antibodies. JACC Case Rep 2024; 29:102234. [PMID: 38464793 PMCID: PMC10920136 DOI: 10.1016/j.jaccas.2024.102234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 03/12/2024]
Abstract
Early stent thrombosis is a rare complication of percutaneous intervention and is associated with significant 30-day mortality. We present a novel case of multiple recurrent early stent thrombosis consistent with spontaneous vaccine-induced thrombotic thrombocytopenia. We were successfully able to manage this unusual condition through an interdisciplinary collaboration.
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Affiliation(s)
- Zulqarnain Khan
- University of Maryland School of Medicine, Department of Internal Medicine, Cardiovascular Division, Baltimore, Maryland, USA
| | - Imari Patel
- University of Maryland School of Medicine, Department of Internal Medicine, Hematology/Oncology Division, Baltimore, Maryland, USA
| | - Tiffany Gardner
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Xin Wei
- University of Maryland School of Medicine, Department of Internal Medicine, Cardiovascular Division, Baltimore, Maryland, USA
| | - Michael Cheng
- University of Maryland School of Medicine, Department of Internal Medicine, Cardiovascular Division, Baltimore, Maryland, USA
| | - Mark R Vesely
- University of Maryland School of Medicine, Department of Internal Medicine, Cardiovascular Division, Baltimore, Maryland, USA
| | - Roberto M Benitez
- University of Maryland School of Medicine, Department of Internal Medicine, Cardiovascular Division, Baltimore, Maryland, USA
| | - Ann B Zimrin
- University of Maryland School of Medicine, Department of Internal Medicine, Hematology/Oncology Division, Baltimore, Maryland, USA
| | - Libin Wang
- University of Maryland School of Medicine, Department of Internal Medicine, Cardiovascular Division, Baltimore, Maryland, USA
| | - Aloke V Finn
- University of Maryland School of Medicine, Department of Internal Medicine, Cardiovascular Division, Baltimore, Maryland, USA
- CVPath Institute Inc, Gaithersburg, Maryland, USA
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7
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Zhang Y, Bissola AL, Treverton J, Hack M, Lychacz M, Kwok S, Arnold A, Nazy I. Vaccine-Induced Immune Thrombotic Thrombocytopenia: Clinicopathologic Features and New Perspectives on Anti-PF4 Antibody-Mediated Disorders. J Clin Med 2024; 13:1012. [PMID: 38398325 PMCID: PMC10889051 DOI: 10.3390/jcm13041012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/29/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare yet severe adverse complication first identified during the global vaccination effort against SARS-CoV-2 infection, predominantly observed following administration of the ChAdOx1-S (Oxford-AstraZeneca) and Ad26.CoV2.S (Johnson & Johnson/Janssen) adenoviral vector-based vaccines. Unlike other anti-platelet factor 4 (PF4) antibody-mediated disorders, such as heparin-induced thrombocytopenia (HIT), VITT arises with the development of platelet-activating anti-PF4 antibodies 4-42 days post-vaccination, typically featuring thrombocytopenia and thrombosis at unusual sites. AIM To explore the unique properties, pathogenic mechanisms, and long-term persistence of VITT antibodies in patients, in comparison with other anti-PF4 antibody-mediated disorders. DISCUSSION This review highlights the complexity of VITT as it differs in antibody behavior and clinical presentation from other anti-PF4-mediated disorders, including the high incidence rate of cerebral venous sinus thrombosis (CVST) and the persistence of anti-PF4 antibodies, necessitating a re-evaluation of long-term patient care strategies. The nature of VITT antibodies and the underlying mechanisms triggering their production remain largely unknown. CONCLUSION The rise in awareness and subsequent prompt recognition of VITT is paramount in reducing mortality. As vaccination campaigns continue, understanding the role of adenoviral vector-based vaccines in VITT antibody production is crucial, not only for its immediate clinical implications, but also for developing safer vaccines in the future.
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Affiliation(s)
- Yi Zhang
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON L8S 4K1, Canada; (Y.Z.); (J.T.); (M.H.); (S.K.)
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON L8S 4K1, Canada; (A.-L.B.); (M.L.)
| | - Anna-Lise Bissola
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON L8S 4K1, Canada; (A.-L.B.); (M.L.)
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Jared Treverton
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON L8S 4K1, Canada; (Y.Z.); (J.T.); (M.H.); (S.K.)
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON L8S 4K1, Canada; (A.-L.B.); (M.L.)
| | - Michael Hack
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON L8S 4K1, Canada; (Y.Z.); (J.T.); (M.H.); (S.K.)
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON L8S 4K1, Canada; (A.-L.B.); (M.L.)
| | - Mark Lychacz
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON L8S 4K1, Canada; (A.-L.B.); (M.L.)
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Sarah Kwok
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON L8S 4K1, Canada; (Y.Z.); (J.T.); (M.H.); (S.K.)
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON L8S 4K1, Canada; (A.-L.B.); (M.L.)
| | - Addi Arnold
- Department of Pathology and Laboratory Medicine, Western University, London, ON N6A 5A5, Canada;
| | - Ishac Nazy
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON L8S 4K1, Canada; (Y.Z.); (J.T.); (M.H.); (S.K.)
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON L8S 4K1, Canada; (A.-L.B.); (M.L.)
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8S 4K1, Canada
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8
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Gabarin N, Hack M, Revilla R, Arnold DM, Nazy I. Hematology in the post-COVID era: spotlight on vaccine-induced immune thrombotic thrombocytopenia and a conceptual framework (the 4P's) for anti-PF4 diseases. Expert Rev Hematol 2024; 17:39-45. [PMID: 38149432 DOI: 10.1080/17474086.2023.2298333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/19/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a life-threatening prothrombotic disorder first identified following the introduction of adenoviral vector vaccines for COVID-19. The condition is characterized by anti-PF4 antibodies and clinically presents with thrombocytopenia and thrombosis often in unusual anatomical sites. AREAS COVERED In this review, we discuss the clinical presentation, diagnostic testing, and treatment of VITT. We also review VITT-like syndromes that have been described in patients without previous vaccination. We propose a conceptual framework for the mechanism of anti-PF4 diseases that includes sufficiently high levels of PF4, the presence of a Polyanion that can form immune complexes with PF4, a Pro-inflammatory milieu, and an immunological Predisposition - the 4Ps. EXPERT OPINION Significant progress has been made in understanding the characteristics of the VITT antibody and in testing methods that can confirm that diagnosis. Future work should be directed at understanding long-term outcomes, mechanisms of thrombosis, and individual risk factors for this rare but dangerous immune-thrombotic disease.
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Affiliation(s)
- Nadia Gabarin
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Michael Hack
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Ryan Revilla
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
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9
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Bissola AL, Daka M, Ivetic N, Clare R, Pai M, Kelton JG, Arnold DM, Nazy I. Evaluation of laboratory testing parameters for vaccine-induced immune thrombotic thrombocytopenia and their implications for diagnosis. J Thromb Haemost 2024; 22:304-306. [PMID: 37866513 DOI: 10.1016/j.jtha.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Affiliation(s)
- Anna-Lise Bissola
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mercy Daka
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nikola Ivetic
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rumi Clare
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Menaka Pai
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John G Kelton
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University Hamilton, Hamilton, Ontario, Canada.
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10
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Abdelouahed M, Yateem D, Fredericks S. Fc γRIIa - dependent platelet activation identified in COVID-19 vaccine-induced immune thrombotic thrombocytopenia-, heparin-induced thrombocytopenia, streptokinase- and anisoylated plasminogen-streptokinase activator complex-induced platelet activation. Front Cardiovasc Med 2023; 10:1282637. [PMID: 38034388 PMCID: PMC10684751 DOI: 10.3389/fcvm.2023.1282637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19), which was caused by the coronavirus - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was globally responsible for remarkable morbidity and mortality. Several highly effective vaccines for COVID-19 were developed and disseminated worldwide within an unprecedented timescale. Rare but dangerous clotting and thrombocytopenia events, and subsequent coagulation abnormalities, have been reported after massive vaccination against SARS-CoV-2. Soon after their global rollout, reports of a morbid clinical syndrome following vaccination with adenovirus-DNA-based vaccines appeared. In the spring of 2021, reports of a novel, rare and morbid clinical syndrome, with clinically devastating and fatal complication after vaccination with adenovirus-based coronavirus vaccines (Janssen/Johnson & Johnson and Astra-Zeneca vaccines) led to a brief suspension of their use by several countries. Those complications were associated with unusual cerebral and splanchnic venous thrombosis, and circulating autoantibodies directed against anti-platelet factor 4 (PF4), a protein secreted from platelets, leading to the designation: Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT). The reported VITT incidence remains very low and does not affect the overall benefit of immunization, however, if left untreated, VITT can be debilitating or even fatal. VITT resembled specific adverse drugs' reactions that also involved the production of autoantibodies and subsequent abnormal platelet activation through platelet FcγRIIa. These unusual but well-documented drug reactions were heparin-induced thrombocytopenia (HIT), streptokinase- (SK), and anisoylated plasminogen-streptokinase activator complex- (APSAC) associated with platelet-activating antibodies. There was considerable overlapping of clinical features between VITT, COVID-19 and these adverse drugs' reactions. We review the phenomenon of VITT against the backdrop of shared and common mechanisms that underlie HIT-, SK-, and APSAC-platelet FcγRIIa-dependent platelet activation. An understanding of VITT's pathogenesis may be achieved by comparing and contrasting VITT-, HIT-, SK- and APSAC-induced platelet activation mechanisms, their respective physiopathology and similarities. Discussing these conditions in parallel provides insight into complex immunological disorders and diseases associated with abnormal hemostasis and thrombosis in particular.
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Affiliation(s)
- Mustapha Abdelouahed
- Department of Medical Sciences and Education, Boston University School of Medicine, Boston, MA, United States
| | - Dana Yateem
- School of Medicine, The Royal College of Surgeons in Ireland, Medical University of Bahrain, Al Sayh, Muharraq Governorate, Bahrain
| | - Salim Fredericks
- School of Medicine, The Royal College of Surgeons in Ireland, Medical University of Bahrain, Al Sayh, Muharraq Governorate, Bahrain
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11
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Warkentin TE. Autoimmune Heparin-Induced Thrombocytopenia. J Clin Med 2023; 12:6921. [PMID: 37959386 PMCID: PMC10649402 DOI: 10.3390/jcm12216921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/27/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
Autoimmune thrombocytopenia (aHIT) is a severe subtype of heparin-induced thrombocytopenia (HIT) with atypical clinical features caused by highly pathological IgG antibodies ("aHIT antibodies") that activate platelets even in the absence of heparin. The clinical features of aHIT include: the onset or worsening of thrombocytopenia despite stopping heparin ("delayed-onset HIT"), thrombocytopenia persistence despite stopping heparin ("persisting" or "refractory HIT"), or triggered by small amounts of heparin (heparin "flush" HIT), most cases of fondaparinux-induced HIT, and patients with unusually severe HIT (e.g., multi-site or microvascular thrombosis, overt disseminated intravascular coagulation [DIC]). Special treatment approaches are required. For example, unlike classic HIT, heparin cessation does not result in de-escalation of antibody-induced hemostasis activation, and thus high-dose intravenous immunoglobulin (IVIG) may be indicated to interrupt aHIT-induced platelet activation; therapeutic plasma exchange may be required if high-dose IVIG is ineffective. Also, aHIT patients are at risk for treatment failure with (activated partial thromboplastin time [APTT]-adjusted) direct thrombin inhibitor (DTI) therapy (argatroban, bivalirudin), either because of APTT confounding (where aHIT-associated DIC and resulting APTT prolongation lead to systematic underdosing/interruption of DTI therapy) or because DTI inhibits thrombin-induced protein C activation. Most HIT laboratories do not test for aHIT antibodies, contributing to aHIT under-recognition.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada; ; Tel.: +1-(905)-527-0271 (ext. 46139)
- Service of Benign Hematology, Hamilton Health Sciences (General Site), Hamilton, ON L8L 2X2, Canada
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, ON L8L 2X2, Canada
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12
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Procter TD, Ogasawara H, Spruin S, Wijayasri S, Abraham N, Blaser C, Hutchings K, Shaw A, Ogunnaike-Cooke S. Thrombosis with thrombocytopenia syndrome (TTS) following adenovirus vector COVID-19 vaccination in Canada. Vaccine 2023; 41:6802-6809. [PMID: 37806804 DOI: 10.1016/j.vaccine.2023.09.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/01/2023] [Accepted: 09/29/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Identifying and monitoring adverse events following vaccination contributed to the safety and effectiveness of COVID-19 mass vaccination campaigns. In March 2021, international reports emerged of an adverse event following vaccination with adenovirus vector COVID-19 vaccines (ChAdOx1-S [recombinant] and Ad26.COV2.S) of thrombosis with low platelet counts, referred to as thrombosis with thrombocytopenia syndrome (TTS). We described TTS reports in Canada following adenovirus vector COVID-19 vaccines and investigated whether the observed number of events were higher than expected. METHODS Reports of TTS following receipt of ChAdOx1-S [recombinant] or Ad26.COV2.S meeting the Canadian case definition for TTS and diagnostic certainty levels 1-3 of the Brighton Collaboration case definition, submitted to the Canadian Adverse Events Following Immunization Surveillance System and Canada Vigilance Database between February 26, 2021 and October 31, 2022 were included. Demographics and characteristics of the TTS reports are described along with an analysis comparing the observed number of reports to the expected number. RESULTS As of October 31, 2022, 56 reports of TTS following administration of ChAdOx1-S [recombinant] and no reports following Ad26.COV2.S vaccines were reported in Canada, of which 37 had functionally positive anti-PF4 antibodies. The median age was 56 years; males accounted for 54 % of reports. Five deaths were reported. The observed number of reports exceeded the expected for all ages and sexes combined, as well as for males aged 30-49 and 60-69 years, and females aged 40-59 years. CONCLUSION Based on international surveillance data, Canada evaluated a statistical signal of TTS following adenovirus vector vaccines. The investigation of this signal demonstrated how post-market vaccine safety surveillance systems were successful in investigating rare adverse events during the rollout of COVID-19 vaccines in Canada. As adenovirus vector vaccines continue to be administered, characterization of the association between the vaccine and TTS informs immunization programs and policies.
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Affiliation(s)
- T D Procter
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada.
| | - H Ogasawara
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - S Spruin
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - S Wijayasri
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - N Abraham
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - C Blaser
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - K Hutchings
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - A Shaw
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - S Ogunnaike-Cooke
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
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13
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Warkentin TE. Immunologic Effects of Heparin Associated With Hemodialysis: Focus on Heparin-Induced Thrombocytopenia. Semin Nephrol 2023; 43:151479. [PMID: 38195304 DOI: 10.1016/j.semnephrol.2023.151479] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Intermittent hemodialysis (HD) is almost invariably performed with heparin, and thus HD patients are at risk of developing the immune-mediated adverse effect heparin-induced thrombocytopenia (HIT), caused by anti-platelet factor 4/heparin IgG, which strongly activates platelets. HIT patients develop hypercoagulability with greatly increased risk of thrombosis, both venous and arterial. Certain HIT-associated complications are more likely to develop among HD patients, including hemofilter thrombosis despite heparin, intravascular catheter and/or arteriovenous fistula-associated thrombosis, post-heparin bolus anaphylactoid/anaphylactic reactions, and thrombotic stroke and acute limb artery thrombosis (reflecting the high frequency of underlying arteriopathy in many patients with renal failure). Management of HIT in HD usually requires use of an alternative (non-heparin) anticoagulant; for example, danaparoid sodium (outside the USA) or argatroban (USA and elsewhere). Whether heparin-grafted hemodialyzers (without systemic heparin) can be used safely in acute HIT is unknown. The HIT immune response is remarkably transient and usually not retriggered by subsequent heparin administration. Accordingly, since renal failure patients often require long-term HD, there may be the opportunity-following seroreversion (loss of platelet-activating HIT antibodies)-to restart heparin for HD, a practice that appears to have a low likelihood of retriggering HIT.
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Canada; Service of Benign Hematology, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Canada.
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14
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Faghihi H, Mottaghi-Dastjerdi N, Sharifzadeh M, Rahimi Kakavandi N. ChAdOx1 nCoV-19 Vaccine and Thrombosis with Thrombocytopenia Syndrome among Adults: A Systematic Review. Adv Pharm Bull 2023; 13:723-735. [PMID: 38022808 PMCID: PMC10676559 DOI: 10.34172/apb.2023.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 01/23/2023] [Accepted: 04/24/2023] [Indexed: 12/01/2023] Open
Abstract
Several vaccine-induced thrombotic thrombocytopenia syndrome (VITTS) cases have been reported after the ChAdOx1 nCov-19 vaccination. The current study systematically reviewed the reported post-ChAdOx1 nCoV-19 vaccination thrombotic thrombocytopenia cases. Their laboratory and clinical features, as well as the diagnostic and therapeutic measures, were investigated. Online databases were searched until 25 August 2021. Studies reporting post-ChAdOx1 nCov-19 vaccination thrombotic thrombocytopenia syndrome (TTS) were included. Overall, 167 cases (21-77 years old) from 53 publications were included showing a female dominance of 1.75 times. About 85% of the cases exhibited the primary symptoms within the first two weeks post-vaccination. Headache was the most common initial symptom (>44.2%), and hemorrhage/thrombotic problems (22.46%), as well as discoordination/weakness/numbness/ hemiparesis/cyanotic toes (19.6%), were the most prevalent uncommon initial symptoms. Prothrombin time (PT), D-dimers, and C-reactive protein were the most remarkable increased laboratory parameters in 50.6%, 99.1%, and 55.6% of cases, respectively. In comparison, platelet and fibrinogen were the most remarkable decreased laboratory parameters in 92.7% and 50.5% of cases, respectively. Most VITT cases presented with cerebral venous thrombosis/cerebral venous sinus thrombosis, supraventricular tachycardia, transverse sinus/cerebral thrombosis, pulmonary embolism, and cerebral hemorrhage. Anti-PF4 antibody measurement through immunoassays and functional assays were positive in 86.2% and 73% of cases, respectively. About 31% of the cases died. Early diagnosis and proper therapeutic measures are important in ChAdOx1 nCov-19 vaccine-induced VITTS patients. Therefore, experts are recommended to know the corresponding clinical and laboratory features, as well as diagnostic methods. Elucidation of the pathophysiologic mechanism of ChAdOx1 nCov-19 vaccine-induced TTS deserves further investigation.
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Affiliation(s)
- Homa Faghihi
- Department of Pharmaceutics and Pharmaceutical Nanotechnology, School of Pharmacy Iran University of Medical Sciences, Tehran, Iran
| | - Negar Mottaghi-Dastjerdi
- Department of Pharmacognosy and Pharmaceutical Biotechnology, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sharifzadeh
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Toxicology and Poisoning Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Nader Rahimi Kakavandi
- Department of Toxicology & Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Health and Environment Research Center, Ilam University of Medical Sciences, Ilam, Iran
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15
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Zhou Y, Jiang H, Wei H, Xiao X, Liu L, Ji X, Zhou C. Cerebral venous thrombosis in patients with autoimmune disease, hematonosis or coronavirus disease 2019: Many familiar faces and some strangers. CNS Neurosci Ther 2023; 29:2760-2774. [PMID: 37365966 PMCID: PMC10493677 DOI: 10.1111/cns.14321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/24/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Cerebral venous thrombosis, a rare stroke, is characterized by neurological dysfunction caused by bleeding and/or infarction resulting from venous sinus thrombosis, the so-called venous stroke. Current guidelines recommend anticoagulants as first-line therapy in the treatment of venous stroke. With complicated causes of cerebral venous thrombosis, treatment is difficult, especially when combined with autoimmune diseases, blood diseases, and even COVID-19. AIMS This review summarizes the pathophysiological mechanisms, epidemiology, diagnosis, treatment, and clinical prognosis of cerebral venous thrombosis combined with autoimmune diseases, blood diseases, or infectious diseases such as COVID-19. CONCLUSION A systematic understanding of particular risk factors that should not be neglected when unconventional cerebral venous thrombosis occurs and for a scientific understanding of pathophysiological mechanisms, clinical diagnosis, and treatment, thus contributing to knowledge on special types of venous stroke.
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Affiliation(s)
- Yifan Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Jiang
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Wei
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Xuechun Xiao
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Lu Liu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chen Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
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16
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Huynh A, Arnold DM, Ivetic N, Clare R, Hadzi-Tosev M, Liu Y, Smith JW, Bissola AL, Daka M, Kelton JG, Nazy I. Antibodies against platelet factor 4 and the risk of cerebral venous sinus thrombosis in patients with vaccine-induced immune thrombotic thrombocytopenia. J Thromb Haemost 2023; 21:2833-2843. [PMID: 37394121 DOI: 10.1016/j.jtha.2023.06.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare complication of adenoviral vector-based vaccines against SARS-CoV-2. This syndrome is caused by antibodies against platelet factor 4 (PF4; CXCL4) that lead to platelet activation and is characterized by thrombocytopenia and thrombosis in unusual locations, including cerebral venous sinus thrombosis (CVST). VITT can be classified based on anti-PF4 antibodies properties in vitro: those that require PF4 to activate platelets (PF4-dependent) and those that can activate platelets without additional PF4 (PF4-independent) in the serotonin release assay. OBJECTIVES We aim to characterize the relationship of VITT platelet-activating profiles with CVST. METHODS We conducted a retrospective cohort study involving patients with confirmed VITT who were tested between March and June 2021. Data were collected with an anonymized form and cases were identified as VITT with high clinical suspicion according to platelet activation assays. Anti-PF4 antibody binding regions on PF4 were further characterized with alanine scanning mutagenesis. RESULTS Of the patients with confirmed VITT (n = 39), 17 (43.6%) had PF4-dependent antibodies and 22 (56.4%) had PF4-independent antibodies. CVST occurred almost exclusively in PF4-independent patients (11 of 22 vs 1 of 17; P < .05). Additionally, PF4-independent antibodies bound to 2 distinct epitopes on PF4, the heparin-binding region and a site typical for heparin-induced thrombocytopenia antibodies, whereas PF4-dependent antibodies bound to only the heparin-binding region. CONCLUSION These findings suggest that VITT antibodies that cause PF4-independent platelet activation represent a unique subset of patients more likely to be associated with CVST, possibly due to the 2 different types of anti-PF4 antibodies.
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Affiliation(s)
- Angela Huynh
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Nikola Ivetic
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rumi Clare
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Milena Hadzi-Tosev
- Michael G DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Yang Liu
- Michael G DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - James W Smith
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anna-Lise Bissola
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Mercy Daka
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - John G Kelton
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael G DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.
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17
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Warkentin TE, Greinacher A. Laboratory Testing for Heparin-Induced Thrombocytopenia and Vaccine-Induced Immune Thrombotic Thrombocytopenia Antibodies: A Narrative Review. Semin Thromb Hemost 2023; 49:621-633. [PMID: 36455619 PMCID: PMC10421650 DOI: 10.1055/s-0042-1758818] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombotic thrombocytopenia (VITT) are highly prothrombotic (thrombosis frequency ≥50%). Both are caused by platelet-activating anti-platelet factor 4 (PF4) antibodies, forming PF4/IgG-containing immune complexes that engage platelet FcγIIa receptors, producing strong platelet activation. In HIT, heparin crosslinks several PF4 molecules, whereas in VITT, anti-PF4 antibodies alone crosslink PF4. Sufficient levels of circulating anti-PF4 antibodies are needed to create the pathogenic immune complexes on platelet surfaces; this explains why certain serum (plasma)-based assays are highly sensitive for detecting HIT/VITT antibodies. Accordingly, HIT and VITT are "clinical-pathological" disorders, that is, positive testing for such antibodies-together with a compatible clinical picture-is integral for diagnosis. Heparin (low concentrations) enhances HIT antibody-induced platelet activation, but platelet activation by VITT sera is usually inhibited by heparin. For both HIT and VITT, high sensitivity (>99% and >95%, respectively) characterizes PF4-dependent enzyme immunoassays (EIAs) and PF4-enhanced platelet activation assays; in contrast, certain rapid immunoassays have high sensitivity for HIT (>90-97%) but poor sensitivity (<25%) for VITT. HIT and VITT antibodies are directed at distinct sites on PF4: solid-phase EIAs and platelet activation assays are indifferent to these distinct antigen targets, but rapid immunoassays are not. We discuss a conceptual model where PF4 is viewed as a "globe," with the heparin-binding site the "equator"; in this model, HIT antibodies are primarily directed at antigen site(s) at the north and south "poles" of PF4 (formed when PF4 binds to heparin), whereas VITT antibodies recognize sites on the equator.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
- Service of Benign Hematology, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Andreas Greinacher
- Institute for Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
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18
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De Vita A, Franceschi F, Covino M. Increased Thrombotic Risk in COVID-19: Evidence and Controversy. J Clin Med 2023; 12:4441. [PMID: 37445476 DOI: 10.3390/jcm12134441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
The pandemic of respiratory disease caused by the novel coronavirus named SARS-CoV-2, which emerged at the end of 2019, is still ongoing [...].
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Affiliation(s)
- Antonio De Vita
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Francesco Franceschi
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Marcello Covino
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
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19
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Cheung CKM, Law KWT, Law AWH, Law MF, Ho R, Wong SH. Efficacy of Vaccine Protection Against COVID-19 Virus Infection in Patients with Chronic Liver Diseases. J Clin Transl Hepatol 2023; 11:718-735. [PMID: 36969905 PMCID: PMC10037513 DOI: 10.14218/jcth.2022.00339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/22/2022] [Accepted: 11/14/2022] [Indexed: 01/19/2023] Open
Abstract
The outbreak of coronavirus disease 2019 (COVID-19) has resulted in significant morbidity and mortality worldwide. Vaccination against coronavirus disease 2019 is a useful weapon to combat the virus. Patients with chronic liver diseases (CLDs), including compensated or decompensated liver cirrhosis and noncirrhotic diseases, have a decreased immunologic response to coronavirus disease 2019 vaccines. At the same time, they have increased mortality if infected. Current data show a reduction in mortality when patients with chronic liver diseases are vaccinated. A suboptimal vaccine response has been observed in liver transplant recipients, especially those receiving immunosuppressive therapy, so an early booster dose is recommended to achieve a better protective effect. Currently, there are no clinical data comparing the protective efficacy of different vaccines in patients with chronic liver diseases. Patient preference, availability of the vaccine in the country or area, and adverse effect profiles are factors to consider when choosing a vaccine. There have been reports of immune-mediated hepatitis after coronavirus disease 2019 vaccination, and clinicians should be aware of that potential side effect. Most patients who developed hepatitis after vaccination responded well to treatment with prednisolone, but an alternative type of vaccine should be considered for subsequent booster doses. Further prospective studies are required to investigate the duration of immunity and protection against different viral variants in patients with chronic liver diseases or liver transplant recipients, as well as the effect of heterologous vaccination.
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Affiliation(s)
- Carmen Ka Man Cheung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | | | | | - Man Fai Law
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Rita Ho
- Department of Medicine, North District Hospital, Hong Kong, China
| | - Sunny Hei Wong
- Institute of Digestive Disease and Department of Medicine and Therapeutics, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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20
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Divas R, Prabhat R, Rohit R, Sanjay CA, Sushan H, Bijaya R. Covishield vaccination and pulmonary thromboembolism: A coincidence or a causal association? Clin Case Rep 2023; 11:e7468. [PMID: 37305866 PMCID: PMC10248195 DOI: 10.1002/ccr3.7468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/19/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023] Open
Abstract
With the eruption of COVID pandemic, many cases of thromboembolic events in association with the COVID infection were reported suggesting the prothrombotic state associated with the infection. After a few years, eventually some of the COVID vaccines came into implementation. With the discovery and implementation of COVID vaccinations, a very few cases have been reported to have developed thromboembolic events, including pulmonary thromboembolism. Different types of vaccines have been associated with different rates of thromboembolic events. Covishield vaccine is rarely associated with thrombotic complications. In the case report below, we present a case summary of a young married female, who presented with shortness of breath a week after the Covishield vaccination and presented to our tertiary care center with further worsening of symptoms during a course of 6 months. On detailed workup, she was diagnosed to have a large pulmonary thrombus affecting the left main pulmonary artery. Other possible etiologies of the hypercoagulable states were ruled out. Though COVID vaccines are known to induce prothrombotic state in the body, we could not be sure if it was the actual cause for the pulmonary thromboembolism or just a coincidence.
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Affiliation(s)
- Rijal Divas
- Department of Critical Care MedicineTribhuvan University Teaching HospitalMaharajgu, KathmanduNepal
| | - Rijal Prabhat
- Department of Internal MedicineAll India Institute of Medical SciencesRishikeshUttarakhandIndia
| | - Raina Rohit
- Department of Internal MedicineAll India Institute of Medical SciencesRishikeshUttarakhandIndia
| | - Chaudhari Ashish Sanjay
- Department of Internal MedicineAll India Institute of Medical SciencesRishikeshUttarakhandIndia
| | - Homagain Sushan
- Department of Critical Care MedicineTribhuvan University Teaching HospitalMaharajgu, KathmanduNepal
| | - Rawol Bijaya
- Department of Critical Care MedicineTribhuvan University Teaching HospitalMaharajgu, KathmanduNepal
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21
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Favas TT, Lall N, Joshi D, Singh VK, Pathak A, Chakravarty K, Mishra VN, Chaurasia RN, Kumar A. Thrombotic and Thromboembolic Complications After Vaccination Against COVID-19: A Systematic Review. Cureus 2023; 15:e37275. [PMID: 37182082 PMCID: PMC10167937 DOI: 10.7759/cureus.37275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 05/16/2023] Open
Abstract
Thromboembolic complications after the COVID-19 vaccination have been reported from all over the world. We aimed to identify the thrombotic and thromboembolic complications that can arise after receiving various types of COVID-19 vaccines, their frequency, and distinguishing characteristics. Articles published in Medline/PubMed, Scopus, EMBASE, Google Scholar, EBSCO, Web of Science, the Cochrane Library, the CDC database, the WHO database, ClinicalTrials.gov, and servers like medRxiv.org and bioRxiv.org, as well as the websites of several reporting authorities between December 1, 2019, and July 29, 2021, were searched. Studies were included if they reported any thromboembolic complications post-COVID-19 vaccination and excluded editorials, systematic reviews, meta-analyses, narrative reviews, and commentaries. Two reviewers independently extracted the data and conducted the quality assessment. Thromboembolic events and associated hemorrhagic complications after various types of COVID-19 vaccines, their frequency, and distinguishing characteristics were assessed. The protocol was registered at PROSPERO (ID-CRD42021257862). There were 59 articles, enrolling 202 patients. We also studied data from two nationwide registries and surveillance. The mean age of presentation was 47 ± 15.5 (mean ± SD) years, and 71.1% of the reported cases were females. The majority of events were with the AstraZeneca vaccine and with the first dose. Of these, 74.8% were venous thromboembolic events, 12.7% were arterial thromboembolic events, and the rest were hemorrhagic complications. The most common reported event was cerebral venous sinus thrombosis (65.8%), followed by pulmonary embolism, splanchnic vein thrombosis, deep vein thrombosis, and ischemic and hemorrhagic stroke. The majority had thrombocytopenia, high D-dimer, and anti-PF4 antibodies. The case fatality rate was 26.5%. In our study, 26/59 of the papers were of fair quality. The data from two nationwide registries and surveillance revealed 6347 venous and arterial thromboembolic events post-COVID-19 vaccinations. COVID-19 vaccinations have been linked to thrombotic and thromboembolic complications. However, the benefits far outweigh the risks. Clinicians should be aware of these complications because they may be fatal and because prompt identification and treatment can prevent fatalities.
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Affiliation(s)
- T T Favas
- Department of Neurology, Institute of Medical Science, Banaras Hindu University, Varanasi, IND
| | - Neha Lall
- Department of Radiation Oncology, Mahamana Pandit Madan Mohan Malaviya Cancer Centre, Varanasi, IND
| | - Deepika Joshi
- Department of Neurology, Institute of Medical Science, Banaras Hindu University, Varanasi, IND
| | - Varun K Singh
- Department of Neurology, Institute of Medical Science, Banaras Hindu University, Varanasi, IND
| | - Abhishek Pathak
- Department of Neurology, Institute of Medical Science, Banaras Hindu University, Varanasi, IND
| | - Kamalesh Chakravarty
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Vijaya Nath Mishra
- Department of Neurology, Institute of Medical Science, Banaras Hindu University, Varanasi, IND
| | - Rameshwar N Chaurasia
- Department of Neurology, Institute of Medical Science, Banaras Hindu University, varanasi, IND
| | - Anand Kumar
- Department of Neurology, Institute of Medical Science, Banaras Hindu University, Varanasi, IND
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22
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Xie B, Semaan DB, Sridharan ND, Eslami MH, Go C. Acute limb ischemia secondary to vaccine-induced thrombotic thrombocytopenia. ANNALS OF VASCULAR SURGERY. BRIEF REPORTS AND INNOVATIONS 2023; 3:100153. [PMID: 36776715 PMCID: PMC9912189 DOI: 10.1016/j.avsurg.2022.100153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Vaccine-associated thrombosis has previously been described in patients presenting with cerebral sinus thrombosis, deep venous thrombosis/pulmonary embolism, or mesenteric venous thrombosis. Only recently has arterial thrombosis gained attention. A new entity known as vaccine-induced thrombotic thrombocytopenia (VITT) has been associated with the coronavirus disease of 2019 (COVID-19) vaccines produced by AstraZeneca and Johnson & Johnson. We describe a case series of three patients who presented with acute limb ischemia with vaccine-associated arterial occlusions, one of whom was diagnosed with VITT.
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Affiliation(s)
- Bowen Xie
- Division of Vascular Surgery, UPMC, Pittsburgh, PA
| | | | | | | | - Catherine Go
- Division of Vascular Surgery, UPMC, Pittsburgh, PA
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23
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Angeli F, Zappa M, Reboldi G, Gentile G, Trapasso M, Spanevello A, Verdecchia P. The spike effect of acute respiratory syndrome coronavirus 2 and coronavirus disease 2019 vaccines on blood pressure. Eur J Intern Med 2023; 109:12-21. [PMID: 36528504 PMCID: PMC9744686 DOI: 10.1016/j.ejim.2022.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/14/2022]
Abstract
Among the various comorbidities potentially worsening the clinical outcome in patients hospitalized for the acute respiratory syndrome coronavirus-2 (SARS-CoV-2), hypertension is one of the most prevalent. However, the basic mechanisms underlying the development of severe forms of coronavirus disease 2019 (COVID-19) among hypertensive patients remain undefined and the direct association of hypertension with outcome in COVID-19 is still a field of debate. Experimental and clinical data suggest that SARS-CoV-2 infection promotes a rise in blood pressure (BP) during the acute phase of infection. Acute increase in BP and high in-hospital BP variability may be tied with acute organ damage and a worse outcome in patients hospitalized for COVID-19. In this context, the failure of the counter-regulatory renin-angiotensin-system (RAS) axis is a potentially relevant mechanism involved in the raise in BP. It is well recognized that the efficient binding of the Spike (S) protein to angiotensin converting enzyme 2 (ACE2) receptors mediates the virus entry into cells. Internalization of ACE2, downregulation and malfunction predominantly due to viral occupation, dysregulates the protective RAS axis with increased generation and activity of angiotensin (Ang) II and reduced formation of Ang1,7. Thus, the imbalance between Ang II and Ang1-7 can directly contribute to excessively rise BP in the acute phase of SARS-CoV-2 infection. A similar mechanism has been postulated to explain the raise in BP following COVID-19 vaccination ("Spike Effect" similar to that observed during the infection of SARS-CoV-2). S proteins produced upon vaccination have the native-like mimicry of SARS-CoV-2 S protein's receptor binding functionality and prefusion structure and free-floating S proteins released by the destroyed cells previously targeted by vaccines may interact with ACE2 of other cells, thereby promoting ACE2 internalization and degradation, and loss of ACE2 activities.
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Affiliation(s)
- Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese, 21100, Italy; Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, 21049, Italy.
| | - Martina Zappa
- Department of Medicine and Surgery, University of Insubria, Varese, 21100, Italy
| | - Gianpaolo Reboldi
- Department of Medicine, and Centro di Ricerca Clinica e Traslazionale (CERICLET), University of Perugia, Perugia, 06100, Italy
| | - Giorgio Gentile
- College of Medicine and Health. University of Exeter, Exeter, United Kingdom and Department of Nephrology, Royal Cornwall Hospitals NHS Trust, Truro, United Kingdom
| | - Monica Trapasso
- Dipartimento di Igiene e Prevenzione Sanitaria, PSAL, Sede Territoriale di Varese, ATS Insubria, Varese, 21100, Italy
| | - Antonio Spanevello
- Department of Medicine and Surgery, University of Insubria, Varese, 21100, Italy; Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, 21049, Italy
| | - Paolo Verdecchia
- Division of Cardiology, Hospital S. Maria della Misericordia, Perugia, and Fondazione Umbra Cuore e Ipertensione-ONLUS, Perugia, 06100, Italy
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24
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Hosseini R, Askari N. A review of neurological side effects of COVID-19 vaccination. Eur J Med Res 2023; 28:102. [PMID: 36841774 PMCID: PMC9959958 DOI: 10.1186/s40001-023-00992-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 01/04/2023] [Indexed: 02/27/2023] Open
Abstract
Following the COVID-19 virus epidemic, extensive, coordinated international research has led to the rapid development of effective vaccines. Although vaccines are now considered the best way to achieve collective safety and control mortality, due to the critical situation, these vaccines have been issued the emergency use licenses and some of their potential subsequence side effects have been overlooked. At the same time, there are many reports of side effects after getting a COVID-19 vaccine. According to these reports, vaccination can have an adverse event, especially on nervous system. The most important and common complications are cerebrovascular disorders including cerebral venous sinus thrombosis, transient ischemic attack, intracerebral hemorrhage, ischemic stroke, and demyelinating disorders including transverse myelitis, first manifestation of MS, and neuromyelitis optica. These effects are often acute and transient, but they can be severe and even fatal in a few cases. Herein, we have provided a comprehensive review of documents reporting neurological side effects of COVID-19 vaccines in international databases from 2020 to 2022 and discussed neurological disorders possibly caused by vaccination.
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Affiliation(s)
- Roya Hosseini
- grid.412503.10000 0000 9826 9569Department of Biology, Faculty of Sciences, Shahid Bahonar University of Kerman, P.O.Box 76135-133, Kerman, Islamic Republic of Iran
| | - Nayere Askari
- Department of Biology, Faculty of Sciences, Shahid Bahonar University of Kerman, P.O.Box 76135-133, Kerman, Islamic Republic of Iran. .,Immunoregulation Research Center, Shahed University, Tehran, Islamic Republic of Iran.
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25
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Ishibashi Y, Takama N, Fujii T, Takizawa D, Amanai S, Kuno T, Aihara K, Koitabashi N, Ishii H. Acute pulmonary thromboembolism after messenger RNA vaccination against coronavirus disease 2019: A case report. J Cardiol Cases 2023:S1878-5409(23)00025-7. [PMID: 36846298 PMCID: PMC9939391 DOI: 10.1016/j.jccase.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/21/2023] [Accepted: 02/01/2023] [Indexed: 02/22/2023] Open
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is defined as thrombosis after inoculation of adenovirus vector vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). VITT rarely occurs with messenger RNA vaccines, and the use of heparin for VITT is also controversial. A 74-year-old female patient with no risk factors for thrombosis was brought to our hospital after loss of consciousness. Nine days before admission, she had received the third vaccine against SARS-CoV-2 (mRNA1273, Moderna). Immediately after transport, cardiopulmonary arrest occurred, prompting extracorporeal membrane oxygenation (ECMO). Pulmonary angiography showed translucent images of both pulmonary arteries, resulting in the diagnosis of acute pulmonary thromboembolism. Unfractionated heparin was administered, but D-dimer subsequently became negative. Pulmonary thrombosis remained in large volume, indicating that heparin was ineffective. Treatment was shifted to anticoagulant therapy using argatroban, which increased D-dimer level and improved respiratory status. The patient was successfully weaned from ECMO and ventilator. Anti-platelet factor 4 antibody examined after treatment initiation showed negative results; however, VITT was considered as an underlying condition because of the time of onset after vaccination, the ineffectiveness of heparin, and the absence of other causes of thrombosis. In case heparin is not effective, argatroban can be an alternative therapy against thrombosis. Learning objective During the coronavirus disease 2019 pandemic, treatment with vaccine against severe acute respiratory syndrome coronavirus 2 has been widely performed. Vaccine-induced immune thrombotic thrombocytopenia is the most common thrombosis after adenovirus vector vaccines. However, thrombosis can also occur after messenger RNA vaccination. Though commonly used for thrombosis, heparin may be ineffective. Non-heparin anticoagulants should be considered.
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Affiliation(s)
- Yohei Ishibashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Noriaki Takama
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takaaki Fujii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Daiki Takizawa
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shiro Amanai
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takahiro Kuno
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Kazufumi Aihara
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Norimichi Koitabashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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26
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Uzun G, Althaus K, Hammer S, Wanner Y, Nowak-Harnau S, Enkel S, Bakchoul T. Diagnostic Performance of a Particle Gel Immunoassay in Vaccine-Induced Immune Thrombotic Thrombocytopenia. Hamostaseologie 2023; 43:22-27. [PMID: 36807823 DOI: 10.1055/a-1986-1556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare but serious complication of adenoviral vector-based COVID-19 vaccines. Similar to heparin-induced thrombocytopenia (HIT), antibodies reacting to platelet factor 4 (PF4) are responsible for platelet activation in VITT. The diagnosis of VITT includes the detection of anti-PF4 antibodies. Particle gel immunoassay (PaGIA) is one of the rapid immunoassays that is commonly used in the diagnosis of HIT to detect anti-PF4 antibodies. The aim of this study was to investigate the diagnostic performance of PaGIA in patients suspected of VITT. In this retrospective, single-center study, the correlation between PaGIA, enzyme immunoassay (EIA), and modified heparin-induced platelet aggregation assay (HIPA) in patients with findings suggestive of VITT was investigated. A commercially available PF4 rapid immunoassay (ID PaGIA H/PF4, Bio-Rad-DiaMed GmbH, Switzerland) and an anti-PF4/heparin EIA (ZYMUTEST HIA IgG, Hyphen Biomed) were used according to manufacturer's instructions. Modified HIPA was accepted as the gold standard test. Between March 8 and November 19, 2021, a total of 34 samples from clinically well-characterized patients (14 males, 20 females, mean age: 48.2 ± 18.2 years) were analyzed with PaGIA, EIA, and modified HIPA. VITT was diagnosed in 15 patients. Sensitivity and specificity of PaGIA were 54 and 67%, respectively. Anti-PF4/heparin optical density values were not significantly different between PaGIA positive and negative samples (p = 0.586). The sensitivity and specificity of EIA, on the other hand, were 87 and 100%, respectively. In conclusion, PaGIA is not reliable in the diagnosis of VITT because of its low sensitivity and specificity.
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Affiliation(s)
- Günalp Uzun
- Centre for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Karina Althaus
- Centre for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany.,Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tuebingen, University Hospital of Tuebingen, Tuebingen, Germany
| | - Stefanie Hammer
- Centre for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Yvonne Wanner
- Centre for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Stefanie Nowak-Harnau
- Centre for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Sigrid Enkel
- Centre for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany.,Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tuebingen, University Hospital of Tuebingen, Tuebingen, Germany
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27
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Doubrovinskaia S, Mooshage CM, Seliger C, Lorenz H, Nagel S, Lehnert P, Purrucker J, Wildemann B, Bendszus M, Wick W, Schönenberger S, Kaulen LD. Neurological autoimmune diseases following vaccinations against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): A follow-up study. Eur J Neurol 2023; 30:463-473. [PMID: 36259114 PMCID: PMC9874608 DOI: 10.1111/ene.15602] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/01/2022] [Accepted: 09/19/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Population-based studies suggest severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines may trigger neurological autoimmunity including immune-mediated thrombotic thrombocytopenia. Long-term characterization of cases is warranted to facilitate patient care and inform vaccine-hesitant individuals. METHODS In this single-center prospective case study with a median follow-up of 387 days long-term clinical, laboratory and imaging characteristics of patients with neurological autoimmunity diagnosed in temporal association (≤6 weeks) with SARS-CoV-2 vaccinations are reported. RESULTS Follow-up data were available for 20 cases (central nervous system demyelinating diseases n = 8, inflammatory peripheral neuropathies n = 4, vaccine-induced immune thrombotic thrombocytopenia n = 3, myositis n = 2, myasthenia n = 1, limbic encephalitis n = 1, giant cell arteritis n = 1). Following therapy, the overall disability level improved (median modified Rankin Scale at diagnosis 3 vs. 1 at follow-up). The condition of two patients worsened despite immunosuppressants possibly related to their autoimmune diagnoses (limbic encephalitis n = 1, giant cell arteritis n = 1). At 12 months' follow-up, 12 patients achieved complete clinical remissions with partial responses in five and stable disease in one case. Correspondingly, autoimmune antibodies were non-detectable or titers had significantly lowered in all, and repeat imaging revealed radiological responses in most cases. Under vigilant monitoring 15 patients from our cohort underwent additional SARS-CoV-2 vaccinations (BNT162b2 n = 12, mRNA-1273 n = 3). Most patients (n = 11) received different vaccines than prior to diagnosis of neurological autoimmunity. Except for one short-lasting relapse, which responded well to steroids, re-vaccinations were well tolerated. CONCLUSIONS In this study long-term characteristics of neurological autoimmunity encountered after SARS-CoV-2 vaccinations are defined. Outcome was favorable in most cases. Re-vaccinations were well tolerated and should be considered on an individual risk/benefit analysis.
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Affiliation(s)
- Sofia Doubrovinskaia
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Christoph M. Mooshage
- Department of NeuroradiologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Corinna Seliger
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Hanns‐Martin Lorenz
- Division of RheumatologyDepartment of Internal Medicine V, University Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Simon Nagel
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
- Department of NeurologyHospital LudwigshafenLudwigshafenGermany
| | - Pascal Lehnert
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Jan Purrucker
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Brigitte Wildemann
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Martin Bendszus
- Department of NeuroradiologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Wolfgang Wick
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Silvia Schönenberger
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
| | - Leon D. Kaulen
- Department of NeurologyUniversity Hospital Heidelberg, Heidelberg UniversityHeidelbergGermany
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28
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Misbah SA, Pavord S, Foster M. Dosing of intravenous immunoglobulin in COVID-19 vaccine-induced immune thrombocytopenia and thrombosis. J Clin Pathol 2023; 76:143-144. [PMID: 36175122 DOI: 10.1136/jcp-2022-208377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/15/2022] [Indexed: 02/02/2023]
Affiliation(s)
- Siraj A Misbah
- Clinical Immunology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sue Pavord
- Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mark Foster
- Haematology, Medical Data Solutions and Services (MDSAS), Manchester, UK
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29
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Abrams CS, Barnes GD. SARS-CoV-2 Vaccination-Induced Thrombotic Thrombocytopenia: A Rare but Serious Immunologic Complication. Annu Rev Med 2023; 74:65-74. [PMID: 35850494 DOI: 10.1146/annurev-med-043021-015237] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Billions of individuals worldwide have benefited from the unprecedented large-scale rollout of COVID-19 vaccines. Given the sheer number of people that have received these vaccines, it is not surprising that rare side effects are reported that were not previously detected in the phase III vaccine trials. This review addresses one rare complication called SARS-CoV-2 vaccination-induced thrombotic thrombocytopenia (VITT). It occurs in approximately 1/50,000 to 1/100,000 recipients of the adenovirus vector-based COVID-19 vaccines made by AstraZeneca-Oxford or Johnson & Johnson. Information on VITT syndrome was disseminated quickly via social media and publications after it was first discovered. Initial observations associating VITT with specific patient populations, thrombus locations, and outcomes associated with heparin therapy have since been refined with additional clinical experience. In this review, we discuss what is currently known about the incidence, pathophysiology, diagnosis, and treatment of VITT.
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Affiliation(s)
- Charles S Abrams
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA;
| | - Geoffrey D Barnes
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA;
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30
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Liu X, Zhang Y, Lu L, Li X, Wu Y, Yang Y, Li T, Cao W. Benefits of high-dose intravenous immunoglobulin on mortality in patients with severe COVID-19: An updated systematic review and meta-analysis. Front Immunol 2023; 14:1116738. [PMID: 36756131 PMCID: PMC9900022 DOI: 10.3389/fimmu.2023.1116738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/10/2023] [Indexed: 01/24/2023] Open
Abstract
Background The clinical benefits of high-dose intravenous immunoglobulin (IVIg) in treating COVID-19 remained controversial. Methods We systematically searched databases up to February 17, 2022, for studies examining the efficacy of IVIg compared to routine care. Meta-analyses were conducted using the random-effects model. Subgroup analysis, meta-regression, and trial series analysis w ere performed to explore heterogeneity and statistical significance. Results A total of 4,711 hospitalized COVID-19 patients (1,925 IVIg treated and 2786 control) were collected from 17 studies, including five randomized controlled trials (RCTs) and 12 cohort studies. The application of IVIg was not associated with all-cause mortality (RR= 0.89 [0.63, 1.26], P= 0.53; I2 = 75%), the length of hospital stays (MD= 0.29 [-3.40, 6.44] days, P= 0.88; I2 = 96%), the needs for mechanical ventilation (RR= 0.93 ([0.73, 1.19], P= 0.31; I2 = 56%), or the incidence of adverse events (RR= 1.15 [0.99, 1.33], P= 0.06; I2 = 20%). Subgroup analyses showed that overall mortality among patients with severe COVID-19 was reduced in the high-dose IVIg subgroup (RR= 0.33 [0.13, 0.86], P= 0.02, I2 = 68%; very low certainty). Conclusions Results of this study suggest that severe hospitalized COVID-19 patients treated with high-dose IVIg would have a lower risk of death than patients with routine care. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021231040, identifier CRD42021231040.
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Affiliation(s)
- Xiaosheng Liu
- Tsinghua-Peking Center for Life Sciences, Beijing, China,Department of Basic Medical Sciences, School of Medicine, Tsinghua University, Beijing, China,Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuelun Zhang
- Medical research center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Lianfeng Lu
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaodi Li
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuanni Wu
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Yang
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Taisheng Li
- Tsinghua-Peking Center for Life Sciences, Beijing, China,Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Cao
- Department of Infectious Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China,*Correspondence: Wei Cao,
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31
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Elfil M, Aladawi M, Balian D, Fahad I, Zhou DJ, Villafuerte-Trisolini B, Diesing TS. Cerebral venous sinus thrombosis after COVID-19 vaccination: a case report and literature review. Oxf Med Case Reports 2023; 2023:omac154. [PMID: 36694608 PMCID: PMC9853928 DOI: 10.1093/omcr/omac154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/09/2022] [Accepted: 12/19/2022] [Indexed: 01/21/2023] Open
Abstract
As COVID-19 vaccines became widely available, there have been reports of neurovascular complications. In this article, we aim to report a case of cerebral venous sinus thrombosis (CVST) induced by COVID-19 vaccination, with a literature review on similar cases as well as the potential pathophysiological mechanisms. Our case is a healthy male who developed headache, vomiting, photophobia and diplopia after receiving the Ad26.COV2.S vaccine. Fundus examination showed papilledema, and magnetic resonance imaging of the brain and cerebral veins showed CVST involving the superior sagittal sinus and right transverse sinus extending into the right jugular vein. Hypercoagulability workup was unremarkable, and the patient received immunotherapy and anticoagulation. Following this treatment, symptoms resolved, and he had no residual neurologic deficits. Developing neurologic manifestations, especially severe headaches with papilledema, after COVID-19 vaccination should warrant neuroimaging. Early recognition and management of CVST are essential for good clinical outcomes.
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Affiliation(s)
- Mohamed Elfil
- Correspondence address. Department of Neurological Sciences, University of Nebraska Medical Center, 988440 Nebraska Medical Center, Omaha, NE 68198-8440, USA. Tel: 402-559-4496; E-mails: ;
| | | | - Dmitry Balian
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ismail Fahad
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Daniel J Zhou
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Thomas Scott Diesing
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
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32
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Zheng X, Gao F, Wang L, Meng Y, Ageno W, Qi X. Incidence and outcomes of splanchnic vein thrombosis after diagnosis of COVID-19 or COVID-19 vaccination: a systematic review and meta-analysis. J Thromb Thrombolysis 2023; 55:18-31. [PMID: 36402911 PMCID: PMC9676885 DOI: 10.1007/s11239-022-02732-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 11/21/2022]
Abstract
Coronavirus disease 2019 (COVID-19) and COVID-19 vaccination may cause splanchnic vein thrombosis (SVT), which is potentially fatal. The present study aims to pool the incidence and outcomes of SVT patients with COVID-19 or having received COVID-19 vaccines. The PubMed, EMBASE, and Cochrane databases were searched. Based on the data from cohort studies, meta-analyses were performed to evaluate the incidence of SVT in COVID-19 patients or people having received COVID-19 vaccines. Pooled proportions were calculated. Based on the individual data from case reports, logistic regression analyses were performed to identify factors associated with death in SVT patients. Odds ratios (ORs) were calculated. Among 654 papers initially identified, 135 were included. Based on 12 cohort studies, the pooled incidence of SVT in COVID-19 patients was 0.6%. Data were insufficient to estimate the incidence of SVT after COVID-19 vaccination. Based on 123 case reports, the mortality was 14% (9/64) in SVT patients with COVID-19 and 25% (15/59) in those who received COVID-19 vaccines. Univariate analyses demonstrated that age (OR = 1.061; p = 0.017), diabetes mellitus (OR = 14.00; p = 0.002), anticoagulation (OR = 0.098; p = 0.004), and bowel resection (OR = 16.00; p = 0.001) were significantly associated with death in SVT patients with COVID-19; and anticoagulation (OR = 0.025; p = 0.003) and intravenous immunoglobulin (OR = 0.175; p = 0.046) were significantly associated with death in SVT patients who received COVID-19 vaccines. Multivariate analyses did not identify any independent factor for death in both patients. SVT in COVID-19 patients and in subjects who received COVID-19 vaccines carries a high mortality, but may be improved by anticoagulation. PROSPERO Identifier CRD42022315254.
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Affiliation(s)
- Xiaojie Zheng
- Department of Gastroenterology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang, 110840 Liaoning China ,grid.412449.e0000 0000 9678 1884Postgraduate College, China Medical University, Shenyang, 110122 China
| | - Fangbo Gao
- Department of Gastroenterology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang, 110840 Liaoning China ,grid.412561.50000 0000 8645 4345Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, 110016 China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang, 110840 Liaoning China ,grid.412449.e0000 0000 9678 1884Postgraduate College, China Medical University, Shenyang, 110122 China
| | - Yao Meng
- Department of Gastroenterology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang, 110840 Liaoning China ,grid.411971.b0000 0000 9558 1426Postgraduate College, Dalian Medical University, Dalian, 116000 China
| | - Walter Ageno
- grid.18147.3b0000000121724807Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China.
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33
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Venier LM, Clerici B, Bissola AL, Modi D, Jevtic SD, Radford M, Mahamad S, Nazy I, Arnold DM. Unique features of vaccine-induced immune thrombotic thrombocytopenia; a new anti-platelet factor 4 antibody-mediated disorder. Int J Hematol 2023; 117:341-348. [PMID: 36574172 PMCID: PMC9793819 DOI: 10.1007/s12185-022-03516-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a highly prothrombotic disorder caused by anti-PF4 antibodies that activate platelets and neutrophils, leading to thrombosis. Heparin-induced thrombocytopenia (HIT) is a related anti-PF4 mediated disorder, with similar pathophysiology and clinical manifestations but different triggers (i.e., heparin vs adenoviral vector vaccine). Clinically, both HIT and VITT typically present with thrombocytopenia and thrombosis, although the risk of thrombosis is significantly higher in VITT, and the thromboses occur in unusual anatomical sites (e.g., cerebral venous sinus thrombosis and hepatic vein thrombosis). The diagnostic accuracy of available laboratory testing differs between HIT and VITT; for VITT, ELISAs have better specificity compared to HIT and platelet activation assays require the addition of PF4. Treatment of VITT and HIT is anticoagulation non-heparin anticoagulants; however, heparin may be considered for VITT if no other option is available.
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Affiliation(s)
- Laura M. Venier
- Faculty of Health Sciences, McMaster University, Hamilton, ON Canada
| | - Bianca Clerici
- Divisione di Medicina Generale II, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy ,McMaster Centre for Transfusion Research, McMaster University, 1280 Main Street West, Room HSC 3H50, Hamilton, ON L8S 4K1 Canada
| | - Anna-Lise Bissola
- Department of Medicine, Michael G. DeGroote School of Medicine, Hamilton, ON Canada ,Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON Canada
| | - Dimpy Modi
- McMaster Centre for Transfusion Research, McMaster University, 1280 Main Street West, Room HSC 3H50, Hamilton, ON L8S 4K1 Canada
| | - Stefan D. Jevtic
- Department of Medicine, Michael G. DeGroote School of Medicine, Hamilton, ON Canada
| | - Michael Radford
- Department of Medicine, Michael G. DeGroote School of Medicine, Hamilton, ON Canada
| | - Syed Mahamad
- McMaster Centre for Transfusion Research, McMaster University, 1280 Main Street West, Room HSC 3H50, Hamilton, ON L8S 4K1 Canada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, Hamilton, ON Canada ,McMaster Centre for Transfusion Research, McMaster University, 1280 Main Street West, Room HSC 3H50, Hamilton, ON L8S 4K1 Canada
| | - Donald M. Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, Hamilton, ON Canada ,McMaster Centre for Transfusion Research, McMaster University, 1280 Main Street West, Room HSC 3H50, Hamilton, ON L8S 4K1 Canada
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34
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Kondo M, Donikian D, Brighton TA. Serotonin Release Assay: Functional Assay for Heparin- and Vaccine-Induced (Immune) Thrombotic Thrombocytopenia. Methods Mol Biol 2023; 2663:463-477. [PMID: 37204730 DOI: 10.1007/978-1-0716-3175-1_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
The serotonin release assay (SRA) has been the gold-standard assay for detection of heparin-dependent platelet-activating antibodies and integral for the diagnosis for heparin-induced thrombotic thrombocytopenia (HIT). In 2021, a thrombotic thrombocytopenic syndrome was reported after adenoviral vector COVID-19 vaccination. This vaccine-induced thrombotic thrombocytopenic syndrome (VITT) proved to be a severe immune platelet activation syndrome manifested by unusual thrombosis, thrombocytopenia, very elevated plasma D-dimer, and a high mortality even with aggressive therapy (anticoagulation and plasma exchange). While the platelet-activating antibodies in both HIT and VITT are directed toward platelet factor 4 (PF4), important differences have been found. These differences have required modifications to the SRA to improve detection of functional VITT antibodies. Functional platelet activation assays remain essential in the diagnostic workup of HIT and VITT. Here we detail the application of SRA for the assessment of HIT and VITT antibodies.
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Affiliation(s)
- Mayuko Kondo
- Haematology Department, New South Wales Health Pathology, Prince of Wales Hospital, Sydney, Australia
| | - Dea Donikian
- Haematology Department, New South Wales Health Pathology, Prince of Wales Hospital, Sydney, Australia
| | - Timothy A Brighton
- Haematology Department, New South Wales Health Pathology, Prince of Wales Hospital, Sydney, Australia.
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35
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Kanack AJ, Jones CG, Singh B, Leger RR, Splinter NP, Heikal NM, Pruthi RK, Chen D, George G, Abou-Ismail MY, Wool GD, Gundabolu K, Padmanabhan A. Off-the-shelf cryopreserved platelets for the detection of HIT and VITT antibodies. Blood 2022; 140:2722-2729. [PMID: 35998675 PMCID: PMC9837435 DOI: 10.1182/blood.2022017283] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/27/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is suspected much more often than it is confirmed. Technically simple platelet factor 4 (PF4)-polyanion enzyme-linked immunosorbent assays (ELISAs) are sensitive but nonspecific. In contrast, accurate functional tests such as the serotonin release assay, heparin-induced platelet activation assay, and PF4-dependent P-selectin expression assay require fresh platelets and have complex assay end points, limiting their availability to specialized reference laboratories. To enable broad deployment of functional testing, we sought to extend platelet viability significantly by optimizing storage conditions and developed a simple functional assay end point by measuring the release of a platelet α-granule protein, thrombospondin-1 (TSP1), in an ELISA format. Platelet cryopreservation conditions were optimized by freezing platelets at controlled cooling rates that preserve activatability. Several-month-old cryopreserved platelets were treated with PF4 or heparin and were evaluated for their ability to be activated by HIT and vaccine-induced immune thrombotic thrombocytopenia (VITT) antibodies in the TSP1 release assay (TRA). HIT and spontaneous HIT patient samples induced significantly higher TSP1 release using both PF4-treated (PF4-TRA) and heparin-treated cryopreserved platelets relative to samples from patients suspected of HIT who lacked platelet-activating antibodies. This latter group included several patients that tested strongly positive in PF4-polyanion ELISA but were not platelet-activating. Four VITT patient samples tested in the TRA activated PF4-treated, but not heparin-treated, cryopreserved platelets, consistent with recent data suggesting the requirement for PF4-treated platelets for VITT antibody detection. These findings have the potential to transform the testing paradigm in HIT and VITT, making decentralized, technically simple functional testing available for rapid and accurate in-hospital diagnosis.
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Affiliation(s)
- Adam J. Kanack
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Bandana Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Noah P. Splinter
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Nahla M. Heikal
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Dong Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Gemlyn George
- Department of Medicine, University of Colorado, Aurora, CO
| | | | | | - Krishna Gundabolu
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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36
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Nakagawa I, Okamoto A, Kotsugi M, Yokoyama S, Yamada S, Nakase H. Endovascular mechanical thrombectomy for cerebral venous sinus thrombosis after mRNA-based SIRS-CoV-2 vaccination. INTERDISCIPLINARY NEUROSURGERY 2022; 30:101644. [PMID: 35966341 PMCID: PMC9364928 DOI: 10.1016/j.inat.2022.101644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/19/2022] [Accepted: 08/07/2022] [Indexed: 12/04/2022] Open
Abstract
Background As vaccinations against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue worldwide, increased rates of venous thrombotic events, mainly as cerebral venous sinus thrombosis (CVST), have been reported following adenovirus vector-based SARS-CoV-2 vaccination. However, few reports have described the occurrence of venous thrombosis after messenger RNA (mRNA)-based vaccination. Here, we describe a case of CVST after a first dose of mRNA-based vaccination that was treated with emergent endovascular mechanical thrombectomy and systemic heparinization. Case Description. A 43-year-old, previously healthy man suffered severe headache and partial seizures affecting the left arm 4 days after receiving the first dose of an mRNA-based SARS-CoV-2 vaccination (FC3661; Pfizer/BioNTech). Computed tomography showed intraparenchymal hemorrhage. Seven days after vaccination, symptoms worsened and he was transferred to our tertiary hospital. Magnetic resonance venography revealed CVST with occlusion of the superior sagittal sinus (SSS) and right transverse sinus (TS). Since no findings suggested thrombosis with thrombocytopenia syndrome, the patient underwent systemic heparinization and emergent mechanical thrombectomy with balloon transluminal angioplasty, a stent retriever and an aspiration catheter. Complete SSS and right TS recanalization were achieved and the patient was discharged without neurological deficits. Conclusion Clinicians should be aware that apparently healthy individuals with no risk factors can develop CVST after receiving an mRNA-based vaccine and appropriate treatment including EMT need to be performed immediately. (228 words)
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Affiliation(s)
- Ichiro Nakagawa
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Ai Okamoto
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Masashi Kotsugi
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Shohei Yokoyama
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Shuichi Yamada
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hiroyuki Nakase
- Departments of Neurosurgery, Nara Medical University, Nara, Japan
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37
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Salih F, Schönborn L, Endres M, Greinacher A. Immunvermittelte Sinus- und Hirnvenenthrombosen: VITT und
prä-VITT als Modellerkrankung. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1936-3123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ZusammenfassungIn diesem Übersichtsartikel beschreiben wir die klinischen und
paraklinischen Charakteristika der Vakzin-induzierten immunthrombotischen
Thrombozytopenie (VITT) und fassen den gegenwärtigen Kenntnisstand zur
Pathogenese zusammen. Bei der VITT bilden sich 5–20 Tage nach einer
Impfung mit einem Adenovirus-vektorbasiertem SARS-CoV-2-Vakzin (AstraZeneca oder
Johnson & Johnson) lebensbedrohliche Thrombosen aus, vor allem in den
zerebralen Sinus und Hirnvenen. Laborchemisch zeigt sich eine typische
Thrombozytopenie mit erhöhten D-Dimeren. Der Pathogenese liegen
immunologische Prozesse zugrunde, die Ähnlichkeiten mit der
Heparin-induzierten Thrombozytopenie aufweisen: so geht die VITT mit
hochtitrigem Immunoglobulin G gegen das thrombozytäre Protein
Plättchenfaktor 4 (PF4) einher. Durch die Interaktion mit dem Impfstoff
wird PF4 so verändert, dass es von Antikörper-produzierenden
Zellen des Immunsystems erkannt wird. Die so produzierten
Anti-PF4-Antikörper führen über thrombozytäre
FcγIIa-Rezeptoren zu einer Plättchenaktivierung. Der Nachweis
plättchenaktivierender Anti-PF4-Antikörper bestätigt die
Diagnose einer VITT. Antikoagulanzien, die die Bildung von Thrombin oder
Thrombin selbst blockieren und hochdosiertes i. v.-Immunglobulin G, das
die Fcγ-Rezeptor-vermittelte Zellaktivierung inhibiert, stellen die
wirksame und kausale Behandlung der VITT dar. Bei Patienten mit katastrophalem
Verlauf kann ein Plasmaaustausch versucht werden. Bei einigen Patienten ist ein
prä-VITT Syndrom als Prodromalstadium zu beoachten, das sich
typischerweise mit Kopfschmerzen manifestieren kann und dessen frühe
Behandlung hilft, thrombotische Komplikationen zu vermeiden. Die spezifische
Dynamik der VITT-assozierten Immunreaktion entspricht einer transienten,
sekundären Immunantwort. Aktuelle Studien gehen der Frage nach, wie PF4
an unterschiedliche adenovirale Proteine bindet und beleuchten die Rolle von
anderen Impfstoff-Bestandteilen als potentielle Liganden für die
PF4-Bindung. Einige dieser Faktoren sind auch an der Etablierung eines
proinflammatorischen Milieus („danger signal“) beteiligt, das
unmittelbar nach der Impfung die 1. Phase der VITT-Pathogenese triggert. Sobald
in der 2. Phase der VITT-Pathogenese hohe Titer von Anti-PF4-Antikörper
gebildet sind, aktivieren diese neben Thrombozyten auch Granulozyten. In einem
als NETose (von „neutrophil extracellular traps“) bezeichneten
Prozess setzen aktivierte Granulozyten dabei DNA frei, mit der PF4 weitere
Komplexe bildet, an die Anti-PF4-Antikörper binden. Dies
verstärkt die Fcγ-Rezeptor-vermittelte Zellaktivierung weiter
mit der Folge einer ausgeprägten Thrombin-Bildung. Zum Ende des Artikels
geben wir einen Ausblick, welchen Einfluss die bisherigen Erkenntnisse zur VITT
auf weitere globale Impfkampagnen gegen SARS-CoV-2 haben und beleuchten, wie
Anti-PF4-Antikörper jenseits von VITT und HIT auch eine Rolle bei
seltenen Erkrankungen spielen, die mit rezidivierenden venösen und
arteriellen Thrombosen einhergehen.
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Affiliation(s)
- Farid Salih
- Klinik für Neurologie mit Experimenteller Neurologie,
Charité Universitätsmedizin Berlin, Berlin,
Germany
| | - Linda Schönborn
- Institut für Transfusionsmedizin, Universitätsmedizin
Greifswald, Greifswald, Germany
| | - Matthias Endres
- Klinik für Neurologie mit Experimenteller Neurologie,
Charité Universitätsmedizin Berlin, Berlin,
Germany
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin
Greifswald, Greifswald, Germany
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Schönborn L, Thiele T, Esefeld M, El Debuch K, Wesche J, Seck SE, Kaderali L, Wolff M, Warkentin TE, Greinacher A. Quantitative interpretation of PF4/heparin-EIA optical densities in predicting platelet-activating VITT antibodies. J Thromb Haemost 2022; 20:2579-2586. [PMID: 36006172 DOI: 10.1111/jth.15862] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a prothrombotic, heparin-induced thrombocytopenia (HIT)-mimicking, adverse reaction caused by platelet-activating anti-platelet factor 4 (PF4) antibodies that occurs rarely after adenovirus vector-based COVID-19 vaccination. Strength of PF4-dependent enzyme immunoassay (EIA) reactivity-judged by optical density (OD) measurements-strongly predicts platelet-activating properties of HIT antibodies in a functional test. Whether a similar relationship holds for VITT antibodies is unknown. OBJECTIVES To evaluate probability for positive platelet activation testing for VITT antibodies based upon EIA OD reactivity; and to investigate simple approaches to minimize false-negative platelet activation testing for VITT. METHODS All samples referred for VITT testing were systematically evaluated by semiquantitative in-house PF4/heparin-EIA (OD readings) and PF4-induced platelet activation (PIPA) testing within a cohort study. EIA-positive sera testing PIPA-negative were retested following 1/4 to 1/10 dilution. Logistic regression was performed to predict the probability of a positive PIPA per magnitude of EIA reactivity. RESULTS Greater EIA ODs in sera from patients with suspected VITT correlated strongly with greater likelihood of PIPA reactivity. Of 61 sera (with OD values >1.0) testing negative in the PIPA, a high proportion (27/61, 44.3%) became PIPA positive when tested at 1/4 to 1/10 dilution. CONCLUSIONS VITT serology resembles HIT in that greater EIA OD reactivity predicts higher probability of positive testing for platelet-activating antibodies. Unlike the situation with HIT antibodies, however, diluting putative VITT serum increases probability of a positive platelet activation assay, suggesting that optimal complex formation depends on the stoichiometric ratio of PF4 and anti-PF4 VITT antibodies.
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Affiliation(s)
- Linda Schönborn
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Max Esefeld
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Khalil El Debuch
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Jan Wesche
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Sabrina E Seck
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Lars Kaderali
- Institute of Bioinformatics, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Martina Wolff
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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Tan LJ, Koh CP, Lai SK, Poh WC, Othman MS, Hussin H. A systemic review and recommendation for an autopsy approach to death followed the COVID 19 vaccination. Forensic Sci Int 2022; 340:111469. [PMID: 36162300 PMCID: PMC9487151 DOI: 10.1016/j.forsciint.2022.111469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/28/2022] [Accepted: 09/18/2022] [Indexed: 11/21/2022]
Abstract
The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) started in December 2019. An immediate prevention approach for the outbreak is the development of a vaccination program. Despite a growing number of publications showing the effectiveness of vaccination in preventing SARS-CoV-2 outbreak and reducing the mortality rate, substantial fatal adverse effects were reported after vaccination. Confirmation of the causal relationship of death is required to reimburse under the national vaccination program and could provide a reference for the selection of vaccination. However, a lack of guidelines in the laboratory study and autopsy approach hampered the investigation of post-vaccination death. In this paper, we performed a systematic electronic search on scientific articles related to severe Covid-19 vaccination adverse effects and approaches in identifying the severe side effects using PubMed and Cochrane libraries. A summary on the onset, biochemistry changes and histopathological analyzes of major lethally side effects post-vaccination were discussed. Ultimately, a checklist is suggested to improve the quality of investigation.
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Affiliation(s)
- Lii Jye Tan
- Department of Forensic Medicine, Hospital Raja Permaisuri Bainun, Ipoh, Perak Darul Ridzuan, Malaysia.
| | - Cai Ping Koh
- Department of Biochemistry, Faculty of Medicine, Quest International University, Malaysia
| | - Shau Kong Lai
- Department of Pathology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
| | - Woon Cheng Poh
- Department of Biochemistry, Faculty of Medicine, Quest International University, Malaysia
| | - Mohammad Shafie Othman
- Department of Forensic Medicine, Hospital Raja Permaisuri Bainun, Ipoh, Perak Darul Ridzuan, Malaysia
| | - Huzlinda Hussin
- Department of Pathology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
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40
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Jevtic SD, Arnold DM, Modi D, Ivetic N, Bissola AL, Nazy I. Vaccine-induced immune thrombotic thrombocytopenia: Updates in pathobiology and diagnosis. Front Cardiovasc Med 2022; 9:1040196. [PMID: 36352844 PMCID: PMC9637757 DOI: 10.3389/fcvm.2022.1040196] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/04/2022] [Indexed: 11/12/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a viral respiratory infection caused by the severe acute respiratory syndrome virus (SARS-CoV-2). Vaccines that protect against SARS-CoV-2 infection have been widely employed to reduce the incidence of symptomatic and severe disease. However, adenovirus-based SARS-CoV-2 vaccines can cause a rare, thrombotic disorder termed vaccine-induced immune thrombotic thrombocytopenia (VITT). VITT often develops in the first 5 to 30 days following vaccination and is characterized by thrombocytopenia and thrombosis in unusual locations (e.g., cerebral venous sinus thrombosis). The diagnosis is confirmed by testing for anti-PF4 antibodies, as these antibodies are capable of platelet activation without any cofactor. It can be clinically challenging to differentiate VITT from a similar disorder called heparin-induced thrombocytopenia (HIT), since heparin is commonly used in hospitalized patients. VITT and HIT have similar pathobiology and clinical manifestations but important differences in testing including the need for PF4-enhanced functional assays and the poor reliability of rapid immunoassays for the detection of anti-platelet factor 4 (PF4) antibodies. In this review we summarize the epidemiology of VITT; highlight similarities and differences between HIT and VITT; and provide an update on the clinical diagnosis of VITT.
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Affiliation(s)
- Stefan D. Jevtic
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Donald M. Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
- Canadian Blood Services, Hamilton, ON, Canada
| | - Dimpy Modi
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Nikola Ivetic
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anna-Lise Bissola
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
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Kanack AJ, Padmanabhan A. Vaccine-induced immune thrombotic thrombocytopenia. Best Pract Res Clin Haematol 2022; 35:101381. [PMID: 36494147 PMCID: PMC9467921 DOI: 10.1016/j.beha.2022.101381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/02/2022] [Accepted: 09/02/2022] [Indexed: 12/14/2022]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is primarily a complication of adenoviral vector-based covid-19 vaccination. In VITT, thrombocytopenia and thrombosis mediated by anti-platelet factor 4 (PF4) antibodies can be severe, often characterized by thrombosis at unusual sites such as the cerebral venous sinus and splanchnic circulation. Like in heparin-induced thrombocytopenia (HIT) and spontaneous HIT, VITT antibodies recognize PF4-polyanion complexes and activate PF4-treated platelets but additionally bind to un-complexed PF4, a critical finding that could be leveraged for more specific detection of VITT. Intravenous immunoglobulin and non-heparin-based anticoagulation remain the mainstay of treatment. Second dose/boosters of mRNA covid-19 vaccines appear safe in patients with adenoviral vector-associated VITT. Emerging data is consistent with the possibility that ultra-rare cases of VITT may be seen in the setting of mRNA and virus-like particle (VLP) technology-based vaccinations and until more data is available, it is prudent to consider VITT in the differential diagnosis of all post-vaccine thrombosis and thrombocytopenia reactions.
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Affiliation(s)
- Adam J Kanack
- Division of Experimental Pathology, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, United States.
| | - Anand Padmanabhan
- Divisions of Hematopathology, Transfusion Medicine & Experimental Pathology, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, United States.
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Angeli F, Reboldi G, Trapasso M, Zappa M, Spanevello A, Verdecchia P. COVID-19, vaccines and deficiency of ACE 2 and other angiotensinases. Closing the loop on the "Spike effect". Eur J Intern Med 2022; 103:23-28. [PMID: 35753869 PMCID: PMC9217159 DOI: 10.1016/j.ejim.2022.06.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/20/2022] [Indexed: 11/03/2022]
Abstract
The role of a dysregulated renin-angiotensin system (RAS) in the pathogenesis of COVID-19 is well recognized. The imbalance between angiotensin II (Ang II) and Angiotensin1-7 (Ang1,7) caused by the interaction between SARS-CoV-2 and the angiotensin converting enzyme 2 (ACE2) receptors exerts a pivotal role on the clinical picture and outcome of COVID-19. ACE2 receptors are not the exclusive angiotensinases in nature. Other angiotensinases (PRCP, and POP) have the potential to limit the detrimental effects of the interactions between ACE2 and the Spike proteins. In the cardiovascular disease continuum, ACE2 activity tends to decrease, and POP/PRCP activity to increase, from the health status to advanced deterioration of the cardiovascular system. The failure of the counter-regulatory RAS axis during the acute phase of COVID-19 is characterized by a decrease of ACE2 expression coupled to unchanged activity of other angiotensinases, therefore failing to limit the accumulation of Ang II. COVID-19 vaccines increase the endogenous synthesis of SARS-CoV-2 spike proteins. Once synthetized, the free-floating spike proteins circulate in the blood, interact with ACE2 receptors and resemble the pathological features of SARS-CoV-2 ("Spike effect" of COVID-19 vaccines). It has been noted that an increased catalytic activity of POP/PRCP is typical in elderly individuals with comorbidities or previous cardiovascular events, but not in younger people. Thus, the adverse reactions to COVID-19 vaccination associated with Ang II accumulation are generally more common in younger and healthy subjects. Understanding the relationships between different mechanisms of Ang II cleavage and accumulation offers the opportunity to close the pathophysiological loop between the risk of progression to severe forms of COVID-19 and the potential adverse events of vaccination.
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Affiliation(s)
- Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese, Italy; Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS, Tradate, Italy.
| | - Gianpaolo Reboldi
- Department of Medicine, and Centro di Ricerca Clinica e Traslazionale (CERICLET), University of Perugia, Perugia, Italy
| | - Monica Trapasso
- Dipartimento di Igiene e Prevenzione Sanitaria, ATS Insubria, PSAL, Sede Territoriale di Varese, Varese, Italy
| | - Martina Zappa
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Antonio Spanevello
- Department of Medicine and Surgery, University of Insubria, Varese, Italy; Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS, Tradate, Italy
| | - Paolo Verdecchia
- Division of Cardiology, Hospital S. Maria Della Misericordia, Perugia, Italy; Fondazione Umbra Cuore e Ipertensione-ONLUS, Perugia, Italy
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Thrombosis after SARS-CoV2 infection or COVID-19 vaccination: will a nonpathologic anti-PF4 antibody be a solution?—A narrative review. JOURNAL OF BIO-X RESEARCH 2022; 5:97-103. [PMID: 36212029 PMCID: PMC9531924 DOI: 10.1097/jbr.0000000000000125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/15/2022] [Indexed: 01/08/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic was triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a previously unknown strain of coronavirus. To fully understand the consequences and complications of SARS-CoV-2 infections, we have reviewed current literature on coagulation dysfunctions that are related to the disease and vaccination. While COVID-19 is more commonly considered as a respiratory illness, studies indicate that, in addition to respiratory illness, a coagulation dysfunction may develop in individuals after the initial infection, placing them at the risk of developing thrombotic events. Patients who died of COVID-19 had higher levels of D-dimer, a biomarker for blood clot formation and breakdown. Effective treatments for coagulation dysfunctions are critically needed to improve patient survival. On the other hand, antibodies against platelet factor 4 (PF4)/heparin may be found in patients with rare instances of vaccine-induced immunological thrombotic thrombocytopenia (VITT) following vaccination with adenovirus-based vaccines. VITT is characterized by atypical thrombosis and thrombocytopenia, similar to immune-mediated heparin-induced thrombocytopenia (HIT), but with no need for heparin to trigger the immune response. Although both adenovirus-based and mRNA-based vaccines express the Spike protein of SARS-CoV-2, VITT is exclusively related to adenovirus-based vaccines. Due to the resemblance with HIT, the use of heparin is highly discouraged against treating patients with thrombotic thrombocytopenia after SARS-CoV-2 infection or with VITT after vaccination. Intravenous immunoglobulin therapy coupled with anticoagulation is recommended instead. The well-studied anti-PF4 monoclonal antibody RTO, which does not induce pathologic immune complexes in the presence of heparin and has been humanized for a potential treatment modality for HIT, may provide a nonanticoagulant HIT-specific solution to the problem of increased blood coagulation after SARS-CoV-2 infection or the VITT after immunization.
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Danis F, Rabani AE, Subhani F, Yasmin S, Koul SS. COVID‐19: Vaccine‐induced immune thrombotic thrombocytopenia (VITT). Eur J Haematol 2022; 109:619-632. [PMID: 36030503 PMCID: PMC9538855 DOI: 10.1111/ejh.13855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | - Salman Shafi Koul
- Pakistan Institute of Medical Sciences, Ibn‐e‐Sina Road, G‐8/3 G 8/3 G‐8 Islamabad Pakistan
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Long-Term Outcomes after Vaccine-Induced Thrombotic Thrombocytopenia. Viruses 2022; 14:v14081702. [PMID: 36016324 PMCID: PMC9415056 DOI: 10.3390/v14081702] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023] Open
Abstract
Vaccine-induced thrombotic thrombocytopenia (VITT), or thrombosis with thrombocytopenia syndrome (TTS), is a rare but serious complication of adenovirus-based vaccines against severe respiratory syndrome coronavirus 2 (SARS-CoV-2). Observation of long-term outcomes is important to guide treatment of affected patients. This single-center consecutive cohort study included all patients diagnosed based on (1) vaccination 4 to 21 days before symptom onset, (2) signs or symptoms of venous or arterial thrombosis, (3) thrombocytopenia < 150/nL, (4) positive anti-platelet factor 4 (PF4) antibody, and (5) elevated D-Dimer > 4 times the upper limit of normal. Nine patients were enrolled. Acute management consisted of parenteral anticoagulants, corticosteroids, intravenous immunoglobulin (IVIG), and/or eculizumab. Eculizumab was successfully used in two patients with recurrent thromboembolic events after IVIG. Direct oral anticoagulants were given after hospital discharge. Median follow-up duration was 300 days (range 153 to 380). All patients survived the acute phase of the disease and were discharged from hospital. One patient died from long-term neurological sequelae of cerebral venous sinus thrombosis 335 days after diagnosis. Eight out of nine patients were alive at last follow-up, and seven had fully recovered. Anti-PF4 antibodies remained detectable for at least 12 weeks after diagnosis, and D-Dimer remained elevated in some patients despite oral anticoagulation. No recurrent thromboembolic events, other signs of VITT relapse, or bleeding complications occurred after discharge. In conclusion, VITT appears to be a highly prothrombotic condition. IVIG is not always successful, and eculizumab may be considered a rescue agent. Long-term management with direct oral anticoagulants appears to be safe and effective.
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46
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Reilly-Stitt C, Jennings I, Kitchen S, Makris M, Meijer P, de Maat M, Scully M, Bakchoul T, Walker ID. Anti-PF4 testing for vaccine-induced immune thrombocytopenia and thrombosis (VITT): Results from a NEQAS, ECAT and SSC collaborative exercise in 385 centers worldwide. J Thromb Haemost 2022; 20:1875-1879. [PMID: 35603519 DOI: 10.1111/jth.15766] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Vaccine-induced immune thrombocytopenia and thrombosis (VITT) following the administration of the AstraZeneca (AZ) ChAdOx1 nCOV-19 vaccine is a well recognized clinical phenomenon. The associated clinical and laboratory features have included thrombosis at unusual sites, thrombocytopenia, raised D-dimer levels and positivity for immunoglobulin G (IgG) anti-platelet factor 4 (PF4) antibodies. OBJECTIVES A collaborative external quality assessment (EQA) exercise was carried out by distributing five lyophilized samples from subjects with VITT and one from a healthy subject to 500 centers performing heparin-induced thrombocytopenia (HIT) testing. METHODS Participating centers employed their locally validated testing methods for HIT assays, with some participants additionally reporting results for VITT modified assays. RESULTS A total of 385 centers returned results for anti-PF4 immunoassay and functional assays. The ELISA assays used in the detection of anti-PF4 antibodies for the samples distributed had superior sensitivities compared with both the functional assays and the non-ELISA methods. CONCLUSION ELISA-based methods to detect anti PF4 antibodies have a greater sensitivity in confirmation of VITT compared with functional assays regardless of whether such functional assays were modified to be specific for VITT. Rapid immunoassays should not be employed to detect VITT antibodies.
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Affiliation(s)
| | | | - Steve Kitchen
- UK NEQAS (Blood Coagulation), Sheffield, UK
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Mike Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Piet Meijer
- ECAT Foundation, Voorschoten, The Netherlands
| | - Moniek de Maat
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marie Scully
- Department of Haematology, University College London Hospitals and Cardiometabolic Programme-NIHR UCLH/UC BRC, London, UK
| | - Tamam Bakchoul
- Medical Faculty of Tubingen, Institute for Clinical and Experimental Transfusion Medicine, Tubingen, Germany
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Harrison H, Rezaei H, Dalal N. A Case of COVID-19 Vaccine-Induced Thrombotic Thrombocytopenia. Cureus 2022; 14:e27204. [PMID: 36039236 PMCID: PMC9395908 DOI: 10.7759/cureus.27204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2022] [Indexed: 11/17/2022] Open
Abstract
This report discusses a case of a 37-year-old female who developed vaccine-induced thrombotic thrombocytopenia (VITT) after receiving the Johnson and Johnson COVID-19 vaccination. The patient first presented to the ED with complaints of a worsening headache. Labs were significant for thrombocytopenia with a platelet count of 22,000, and the patient was admitted to the inpatient unit for monitoring. The day after admission, the patient was found to have a right common femoral artery embolus, left distal popliteal trifurcation embolism, a small pulmonary embolism in the right lower lobe, and a mural thrombus of the infrarenal abdominal aorta. Following these findings, the patient underwent emergent thrombectomy of the common and superficial femoral arteries. Over the hospital course of six days, the patient received steroids and IV immunoglobulin (IVIG), which led to the resolution of the thrombocytopenia. The patient was given argatroban followed by apixaban for anticoagulation. She was instructed to follow up with hematology within one to two weeks post-discharge for monitoring of anticoagulation and thrombus surveillance. This case report outlines the clinical course, diagnosis, and treatment of a case of VITT, which will assist physicians in early recognition and adequate treatment of this condition as the COVID-19 pandemic continues.
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48
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Klemencic Kozul T, Yudina A, Donovan C, Pinto A, Osman C. Cost-minimisation analysis of plasma exchange versus IVIg in the treatment of autoimmune neurological conditions. BMC Health Serv Res 2022; 22:904. [PMID: 35831856 PMCID: PMC9277970 DOI: 10.1186/s12913-022-08210-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 06/07/2022] [Indexed: 11/30/2022] Open
Abstract
Background Plasma exchange (PLEX) is an effective treatment for antibody-mediated neurological disorders and has been shown to be equally efficacious to intravenous immunoglobulin (IVIg) with comparable adverse event profiles. IVIg has traditionally been the preferred treatment option due to its ease of use. However, advancing technology has allowed PLEX to be performed with a centrifugal system via peripheral access as opposed to central access via a membrane filter. Methods We prospectively collected data from a cohort of patients who underwent PLEX at the Wessex Neurological Centre, UK, to perform a cost-minimisation analysis comparing PLEX to IVIg, the standard of care, between May 2019 and May 2020. Data obtained included indication, admission type (inpatient, daycase or intensive care), access (peripheral or central), number of PLEX cycles, exchange volume, patient weight, complications and clinical outcomes. The cost of PLEX delivered in an outpatient setting for an average 80kg person was calculated and compared to the equivalent cost of delivering IVIg by means of a cost-minimization model. Results The provision of PLEX was roughly half as costly when compared to what it would have been for IVIg (£886 per exchange vs £1778 per infusion or £4432 per cycle of 5 exchanges vs £8890 per cycle of 5 infusions). Our cohort included a total of 44 patients who received a total of 357 PLEX exchanges during the 12-month period (the majority of which were in a daycase setting). We calculated an annual cost saving for PLEX over IVIg of £318,589. The robustness of this result was confirmed by a one-way deterministic sensitivity analysis, showing the cost-effectiveness of PLEX. Conclusion Our findings demonstrate that PLEX is more cost-effective than IVIg in this setting. Our study supports the economic case for development of plasma exchange centres in regional neurology units, a case made all the more relevant in the context of constrained supplies of IVIg. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08210-z.
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Affiliation(s)
| | - Anna Yudina
- Terumo Blood and Cell Technologies Europe, Zaventem, Belgium
| | - Carley Donovan
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ashwin Pinto
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Chinar Osman
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Stoll SE, Werner P, Wetsch WA, Dusse F, Bunck AC, Kochanek M, Popp F, Schmidt T, Bruns C, Böttiger BW. Transjugular intrahepatic portosystemic shunt, local thrombaspiration, and lysis for management of fulminant portomesenteric thrombosis and atraumatic splenic rupture due to vector-vaccine-induced thrombotic thrombocytopenia: a case report. J Med Case Rep 2022; 16:271. [PMID: 35821156 PMCID: PMC9274642 DOI: 10.1186/s13256-022-03464-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/17/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction Recombinant adenoviral vector vaccines against severe acute respiratory syndrome coronavirus 2 have been observed to be associated with vaccine-induced immune thrombotic thrombocytopenia. Though vaccine-induced immune thrombotic thrombocytopenia is a rare complication after vaccination with recombinant adenoviral vector vaccines, it can lead to severe complications. In vaccine-induced immune thrombotic thrombocytopenia, the vector vaccine induces heparin-independent production of platelet factor 4 autoantibodies, resulting in platelet activation and aggregation. Therefore, patients suffering from vaccine-induced immune thrombotic thrombocytopenia particularly present with signs of arterial or venous thrombosis, often at atypical sites, but also signs of bleeding due to disseminated intravascular coagulation and severe thrombocytopenia. We describe herein a rare case of fulminant portomesenteric thrombosis and atraumatic splenic rupture due to vaccine-induced immune thrombotic thrombocytopenia. Case summary (main symptoms and therapeutic interventions) This case report presents the diagnosis and treatment of a healthy 29-year-old male Caucasian patient suffering from an extended portomesenteric thrombosis associated with atraumatic splenic rupture due to vaccine-induced immune thrombotic thrombocytopenia after the first dose of an adenoviral vector vaccine against severe acute respiratory syndrome coronavirus 2 [ChAdOx1 nCoV-19 (AZD1222)]. Therapeutic management of vaccine-induced immune thrombotic thrombocytopenia initially focused on systemic anticoagulation avoiding heparin and the application of steroids and intravenous immune globulins as per the recommendations of international societies of hematology and hemostaseology. Owing to the atraumatic splenic rupture and extended portomesenteric thrombosis, successful management of this case required splenectomy with additional placement of a transjugular intrahepatic portosystemic shunt to perform local thrombaspiration, plus repeated local lysis to reconstitute hepatopetal blood flow. Conclusion The complexity and wide spectrum of the clinical picture in patients suffering from vaccine-induced immune thrombotic thrombocytopenia demand an early interdisciplinary diagnostic and therapeutic approach. Severe cases of portomesenteric thrombosis in vaccine-induced immune thrombotic thrombocytopenia, refractory to conservative management, may require additional placement of a transjugular intrahepatic portosystemic shunt, thrombaspiration, thrombolysis, and surgical intervention for effective management.
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Affiliation(s)
- Sandra Emily Stoll
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.
| | - Patrick Werner
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Wolfgang A Wetsch
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Fabian Dusse
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Alexander C Bunck
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Matthias Kochanek
- Department I of Internal Medicine, Intensive Care Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Felix Popp
- Department of General, Visceral, Tumor and Transplantation Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Tumor and Transplantation Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Christiane Bruns
- Department of General, Visceral, Tumor and Transplantation Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Bernd W Böttiger
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
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50
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Kanack AJ, Bayas A, George G, Abou-Ismail MY, Singh B, Kohlhagen MC, Splinter NP, Christ M, Naumann M, Moser KA, Smock KJ, Grazioli A, Wen R, Wang D, Murray DL, Padmanabhan A. Monoclonal and oligoclonal anti-platelet factor 4 antibodies mediate VITT. Blood 2022; 140:73-77. [PMID: 35560046 PMCID: PMC9262283 DOI: 10.1182/blood.2021014588] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 04/24/2022] [Indexed: 11/20/2022] Open
Abstract
Kanack and colleagues analyze anti-platelet factor 4 antibodies from 5 patients with vaccine-induced thrombotic thrombocytopenia (VITT) secondary to COVID-19 adenoviral vaccination and antibodies from patients with spontaneous heparin-induced thrombocytopenia (HIT) and classical HIT. VITT antibodies are monoclonal or oligoclonal, similar to spontaneous HIT, whereas classical HIT antibodies are polyclonal. Heparin inhibits antibody-induced platelet activation in VITT, suggesting that heparin should be considered for the treatment of VITT.
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Affiliation(s)
- Adam J Kanack
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Antonios Bayas
- Department of Neurology and Clinical Neurophysiology, University Hospital of Augsburg, Augsburg, Germany
| | - Gemlyn George
- Department of Medicine, University of Colorado, Aurora, CO
| | | | - Bandana Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Mindy C Kohlhagen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Noah P Splinter
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Monika Christ
- Department of Neurology and Clinical Neurophysiology, University Hospital of Augsburg, Augsburg, Germany
| | - Markus Naumann
- Department of Neurology and Clinical Neurophysiology, University Hospital of Augsburg, Augsburg, Germany
| | - Karen A Moser
- Department of Pathology, University of Utah Health Sciences Center, Salt Lake City, UT
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT
| | - Kristi J Smock
- Department of Pathology, University of Utah Health Sciences Center, Salt Lake City, UT
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT
| | - Alison Grazioli
- National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD; and
| | - Renren Wen
- Blood Research Institute, Versiti, Milwaukee, WI
| | - Demin Wang
- Blood Research Institute, Versiti, Milwaukee, WI
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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