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Habibi S, Hsieh TC, Khanna S. Perioperative Plasma Exchange and Intravenous Immunoglobulin Use for Refractory Heparin-Induced Thrombocytopenia in a Liver Transplant Recipient. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e941865. [PMID: 38158651 PMCID: PMC10765992 DOI: 10.12659/ajcr.941865] [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: 07/21/2023] [Revised: 12/20/2023] [Accepted: 12/06/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious adverse effect of heparin, which can lead to a prothrombotic state. Prompt cessation of heparin and initiation of non-heparin anticoagulation is the standard of care for HIT. Nevertheless, the treatment can pose challenges, particularly in refractory HIT, in patients with contraindications to anticoagulation, or those requiring urgent surgery. Additionally, in rare cases, conventional anticoagulation therapy is not effective, necessitating alternative treatments such as plasma exchange (PLEX) and intravenous immunoglobulin (IVIG). CASE REPORT Here, we report the case of a 57-year-old male patient who developed mild acute cellular rejection, refractory HIT, and disseminated intravascular coagulation after liver transplant surgery. Heparin was stopped and argatroban was initiated for thromboembolism treatment, but hepatic artery thrombosis occurred in the setting of refractory HIT and caused transplant failure. The patient underwent a second liver transplant 1 month after the first surgery. He had 2 sessions of PLEX and received 1 dose of IVIG before and 1 dose during the operation. Despite advanced treatment with PLEX and IVIG, the refractory HIT persisted. Hepatic artery thrombosis recurred within 2 weeks and the transplant failed again despite catheter-directed intra-arterial thrombolysis and argatroban therapy. CONCLUSIONS Recently perioperative PLEX and IVIG have been used a few times for the treatment of refractory HIT. This is the first reported case of a liver transplant recipient with refractory HIT who underwent this treatment strategy. Further investigation is required to determine the efficacy and safety of preoperative and intraoperative administration of PLEX and IVIG, especially in liver transplant recipients with HIT.
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Affiliation(s)
- Shaghayegh Habibi
- Department of Internal Medicine, Lucy Curci Cancer Center, Eisenhower Health, Rancho Mirage, CA, USA
| | - Tien-Chan Hsieh
- Division of Hematology and Oncology, Department of Medicine, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Shrinkhala Khanna
- Division of Hematology and Oncology, Department of Medicine, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
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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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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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Abu Kar S, Kaur A, Khan AM, Bloomfield D. Early Utilization of Intravenous Immunoglobulin in Heparin-Induced Thrombocytopenia for Limb Salvaging Purposes. Cureus 2022; 14:e23202. [PMID: 35449622 PMCID: PMC9012574 DOI: 10.7759/cureus.23202] [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: 03/15/2022] [Indexed: 12/01/2022] Open
Abstract
We present a case of a 28-year-old diabetic female who presented with high-burden lower extremity deep vein thrombosis (DVT) after previous exposure to unfractionated heparin (UFH). Heparin was discontinued, and non-heparin parenteral anticoagulant, argatroban, was started based on a high clinical suspicion of heparin-induced thrombocytopenia with thrombosis (HITT). The diagnosis of HIT was later proven by positive immune and functional assays. The severity of thrombocytopenia and the need for surgical intervention to salvage the limb prompted the use of intravenous immunoglobulin (IVIG) early on in the treatment course to recover platelet counts, halt the prothrombotic state, and prepare the patient for thrombectomy. The patient was put on direct oral anticoagulants (DOACs), apixaban, after thrombectomy, and platelet count recovery with no new thrombosis or bleeding episodes was reported after three months of follow-up.
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Warkentin TE. Platelet-activating anti-PF4 disorders: an overview. Semin Hematol 2022; 59:59-71. [DOI: 10.1053/j.seminhematol.2022.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/11/2022]
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Uzun G, Althaus K, Singh A, Möller P, Ziemann U, Mengel A, Rosenberger P, Guthoff M, Petzold GC, Müller J, Büchsel M, Feil K, Henkes H, Heyne N, Maschke M, Limpach C, Nagel S, Sachs UJ, Fend F, Bakchoul T. The use of IV immunoglobulin in the treatment of vaccine-induced immune thrombotic thrombocytopenia. Blood 2021; 138:992-996. [PMID: 34166507 PMCID: PMC8444699 DOI: 10.1182/blood.2021012479] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/30/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Günalp Uzun
- Center for Clinical Transfusion Medicine, Tuebingen, Germany
| | - Karina Althaus
- Center for Clinical Transfusion Medicine, Tuebingen, Germany
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tuebingen, University Hospital of Tuebingen, Tuebingen, Germany
| | - Anurag Singh
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tuebingen, University Hospital of Tuebingen, Tuebingen, Germany
| | - Peter Möller
- Institute for Pathology, University Hospital of Ulm, Ulm, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany
| | - Peter Rosenberger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Martina Guthoff
- Department of Internal Medicine IV, Section of Nephrology and Hypertension, University Hospital of Tuebingen, Tuebingen, Germany
| | | | - Jens Müller
- Institute for Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Martin Büchsel
- Institute of Clinical Chemistry and Laboratory Medicine, Medical Centre-University of Freiburg, Freiburg im Breisgau, Germany
| | - Katharina Feil
- Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany
| | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Nils Heyne
- Department of Internal Medicine IV, Section of Nephrology and Hypertension, University Hospital of Tuebingen, Tuebingen, Germany
| | - Matthias Maschke
- Department of Neurology, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | - Caroline Limpach
- Department of Neurology, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | - Simon Nagel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulrich J Sachs
- Department of Thrombosis and Hemostasis, Institute of Immunology and Transfusion Medicine, Giessen, Germany; and
| | - Falko Fend
- Institute for Pathology and Neuropathology, University Hospital of Tuebingen, Tuebingen, Germany
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, Tuebingen, Germany
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tuebingen, University Hospital of Tuebingen, Tuebingen, Germany
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Camoin-Jau L, Mariotti A, Suchon P, Morange PE. [Heparin-induced thrombocytopenia: Update]. Rev Med Interne 2021; 43:18-25. [PMID: 34535328 DOI: 10.1016/j.revmed.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/27/2021] [Accepted: 08/29/2021] [Indexed: 11/26/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin therapy. It is due to the synthesis of antibodies most often directed against platelet factor 4 (FP4) modified by heparin (H). HIT is manifested by a platelet count fall, associated with a high risk of venous or arterial thrombosis. The diagnosis of HIT is based on the assessment of clinical probability (4Ts score or change in platelet count after cardiac surgery) and the demonstration of heparin-modified anti-FP4 antibodies (FP4/H). If the immunological tests are positive, functional tests should be performed. In case of suspicion of HIT, it is necessary to urgently stop heparin therapy, to perform a doppler ultrasound of the lower limbs, and to prescribe an alternative anticoagulation agent at a curative dose. Currently, danaparoid sodium and argatroban are authorized. The diagnosis and management of HIT remain complex and requires multidisciplinary collaboration.
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Affiliation(s)
- L Camoin-Jau
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France; Aix-Marseille univsersité, IRD, AP-HM, MEPHI, IHU Méditerranée infection, Marseille, France.
| | - A Mariotti
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France
| | - P Suchon
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France; C2VN, Aix-Marseille université, Inserm, INRAE, Marseille, France
| | - P-E Morange
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France; C2VN, Aix-Marseille université, Inserm, INRAE, Marseille, France
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Bourguignon A, Arnold DM, Warkentin TE, Smith JW, Pannu T, Shrum JM, Al Maqrashi ZAA, Shroff A, Lessard MC, Blais N, Kelton JG, Nazy I. Adjunct Immune Globulin for Vaccine-Induced Immune Thrombotic Thrombocytopenia. N Engl J Med 2021; 385:720-728. [PMID: 34107198 PMCID: PMC8362588 DOI: 10.1056/nejmoa2107051] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The use of high-dose intravenous immune globulin (IVIG) plus anticoagulation is recommended for the treatment of vaccine-induced immune thrombotic thrombocytopenia (VITT), a rare side effect of adenoviral vector vaccines against coronavirus disease 2019 (Covid-19). We describe the response to IVIG therapy in three of the first patients in whom VITT was identified in Canada after the receipt of the ChAdOx1 nCoV-19 vaccine. The patients were between the ages of 63 and 72 years; one was female. At the time of this report, Canada had restricted the use of the ChAdOx1 nCoV-19 vaccine to persons who were 55 years of age or older on the basis of reports that VITT had occurred primarily in younger persons. Two of the patients in our study presented with limb-artery thrombosis; the third had cerebral venous and arterial thrombosis. Variable patterns of serum-induced platelet activation were observed in response to heparin and platelet factor 4 (PF4), indicating the heterogeneity of the manifestations of VITT in serum. After the initiation of IVIG, reduced antibody-induced platelet activation in serum was seen in all three patients. (Funded by the Canadian Institutes of Health Research.).
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Affiliation(s)
- Alex Bourguignon
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
| | - Donald M Arnold
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
| | - Theodore E Warkentin
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
| | - James W Smith
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
| | - Tania Pannu
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
| | - Jeffrey M Shrum
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
| | - Zainab A A Al Maqrashi
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
| | - Anjali Shroff
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
| | - Marie-Claude Lessard
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
| | - Normand Blais
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
| | - John G Kelton
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
| | - Ishac Nazy
- From the Departments of Medicine (A.B., D.M.A., T.E.W., J.W.S., Z.A.A.A.M., A.S., J.G.K., I.N.) and Pathology and Molecular Medicine (A.B., T.E.W.), Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, the Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB (T.P., J.M.S.), the Department of Hematology/Oncology, Centre Hospitalier de l'Université de Montreal, Montreal (N.B.), and the Department of Hematology/Oncology, Hôpital Régional de Saint-Jérôme, St. Jerome, QC (M.-C.L.) - all in Canada
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Rizk JG, Gupta A, Sardar P, Henry BM, Lewin JC, Lippi G, Lavie CJ. Clinical Characteristics and Pharmacological Management of COVID-19 Vaccine-Induced Immune Thrombotic Thrombocytopenia With Cerebral Venous Sinus Thrombosis: A Review. JAMA Cardiol 2021; 6:1451-1460. [PMID: 34374713 DOI: 10.1001/jamacardio.2021.3444] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance The COVID-19 pandemic saw one of the fastest developments of vaccines in an effort to combat an out-of-control pandemic. The 2 most common COVID-19 vaccine platforms currently in use, messenger RNA (mRNA) and adenovirus vector, were developed on the basis of previous research in use of this technology. Postauthorization surveillance of COVID-19 vaccines has identified safety signals, including unusual cases of thrombocytopenia with thrombosis reported in recipients of adenoviral vector vaccines. One of the devastating manifestations of this syndrome, termed vaccine-induced immune thrombotic thrombocytopenia (VITT), is cerebral venous sinus thrombosis (CVST). This review summarizes the current evidence and indications regarding biology, clinical characteristics, and pharmacological management of VITT with CVST. Observations VITT appears to be similar to heparin-induced thrombocytopenia (HIT), with both disorders associated with thrombocytopenia, thrombosis, and presence of autoantibodies to platelet factor 4 (PF4). Unlike VITT, HIT is triggered by recent exposure to heparin. Owing to similarities between these 2 conditions and lack of high-quality evidence, interim recommendations suggest avoiding heparin and heparin analogues in patients with VITT. Based on initial reports, female sex and age younger than 60 years were identified as possible risk factors for VITT. Treatment consists of therapeutic anticoagulation with nonheparin anticoagulants and prevention of formation of autoantibody-PF4 complexes, the latter being achieved by administration of high-dose intravenous immunoglobin (IVIG). Steroids, which can theoretically inhibit the production of new antibodies, have been used in combination with IVIG. In severe cases, plasma exchange should be used for clearing autoantibodies. Monoclonal antibodies, such as rituximab and eculizumab, can be considered when other therapies fail. Routine platelet transfusions, aspirin, and warfarin should be avoided because of the possibility of worsening thrombosis and magnifying bleeding risk. Conclusions and Relevance Adverse events like VITT, while uncommon, have been described despite vaccination remaining the most essential component in the fight against the COVID-19 pandemic. While it seems logical to consider the use of types of vaccines (eg, mRNA-based administration) in individuals at high risk, treatment should consist of therapeutic anticoagulation mostly with nonheparin products and IVIG.
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Affiliation(s)
- John G Rizk
- Arizona State University, Edson College, Phoenix, Arizona
| | - Aashish Gupta
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Partha Sardar
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Brandon Michael Henry
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John C Lewin
- National Coalition on Health Care, Washington, DC
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
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10
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Abstract
Heparin-induced thrombocytopenia is an immune-mediated disorder caused by antibodies that recognize complexes of platelet factor 4 and heparin. Thrombosis is a central and unpredictable feature of this syndrome. Despite optimal management, disease morbidity and mortality from thrombosis remain high. The hypercoagulable state in heparin-induced thrombocytopenia is biologically distinct from other thrombophilic disorders in that clinical complications are directly attributable to circulating ultra-large immune complexes. In some individuals, ultra-large immune complexes elicit unchecked cellular procoagulant responses that culminate in thrombosis. To date, the clinical and biologic risk factors associated with thrombotic risk in heparin-induced thrombocytopenia remain elusive. This review will summarize our current understanding of thrombosis in heparin-induced thrombocytopenia with attention to its clinical features, cellular mechanisms, and its management.
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Affiliation(s)
| | - Anand Padmanabhan
- Divisions of Hematopathology, Transfusion Medicine, and Experimental Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (A.P.)
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11
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Buckley NA, Baskaya MK, Darsie ME. Intravenous Immunoglobulin (IVIG) in Severe Heparin-Induced Thrombocytopenia (HIT) in a Traumatic Brain Injury (TBI) Patient with Cerebral Venous Sinus Thrombosis (CVST). Neurocrit Care 2020; 34:1103-1107. [DOI: 10.1007/s12028-020-01101-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/01/2020] [Indexed: 12/28/2022]
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12
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Onuoha C, Barton KD, Wong EC, Raval JS, Rollins‐Raval MA, Ipe TS, Kiss JE, Boral LI, Adamksi J, Zantek ND, Onwuemene OA. Therapeutic plasma exchange and intravenous immune globulin in the treatment of
heparin‐induced
thrombocytopenia: A systematic review. Transfusion 2020; 60:2714-2736. [DOI: 10.1111/trf.16018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/29/2020] [Accepted: 07/01/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Chinonso Onuoha
- Department of Pediatrics East Carolina University, Vidant Medical Center Greenville North Carolina USA
| | - Karen D. Barton
- Medical Center Library Duke University Medical Center Durham North Carolina USA
| | - Edward C.C. Wong
- Department of Pediatrics and Pathology George Washington School of Medicine and Health Sciences Washington, DC USA
- Department of Coagulation Quest Diagnostics, Nichols Institute Centreville Virginia USA
| | - Jay S. Raval
- Department of Pathology University of New Mexico Albuquerque New Mexico USA
| | | | - Tina S. Ipe
- Department of Pathology and Laboratory Medicine University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Joseph E. Kiss
- Department of Medicine Vitalant Northeast Division and The University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Leonard I. Boral
- Department of Pathology and Laboratory Medicine University of Kentucky Health Care Lexington Kentucky USA
| | - Jill Adamksi
- Department of Laboratory Medicine and Pathology Mayo Clinic Arizona Phoenix Arizona USA
| | - Nicole D. Zantek
- Department of Laboratory Medicine and Pathology University of Minnesota Minneapolis Minnesota USA
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13
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Dougherty JA, Yarsley RL. Intravenous Immune Globulin (IVIG) for Treatment of Autoimmune Heparin-Induced Thrombocytopenia: A Systematic Review. Ann Pharmacother 2020; 55:198-215. [PMID: 32693627 DOI: 10.1177/1060028020943542] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To evaluate intravenous immune globulin (IVIG) for autoimmune heparin-induced thrombocytopenia (aHIT), including platelet recovery, IVIG dose, dosing weight, IVIG product used, and complications reported. DATA SOURCES PubMed and EMBASE were searched from inception through June 21, 2020. Search terms included heparin-induced thrombocytopenia, HIT, intravenous immune globulin, IVIG, autoimmune HIT, aHIT, and immune globulin. STUDY SELECTION AND DATA EXTRACTION Patients administered IVIG for HIT and diagnosed by immunoassay (optical density ≥2) or positive activation assay were included. DATA SYNTHESIS Twenty-four cases were reviewed; 92% had persistent aHIT. Time to IVIG administration post-nonheparin anticoagulant initiation was 9 days (median). Most common IVIG cumulative dose was 2 g/kg (dosed as 1 g/kg/d for 2 consecutive days); 75% had a favorable platelet increase (≥50 × 109/L) within 5 days of initial IVIG dosing. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE aHIT is characterized by critically low platelets, thrombosis, and a persistent delay in platelet recovery despite treatment with a nonheparin anticoagulant. An immunoassay and subsequent confirmatory activation assay (at low, high, and 0 IU/mL unfractionated heparin levels) is recommended to confirm diagnosis. Patients nonresponsive to nonheparin anticoagulants within 5 days of initiation should be evaluated for IVIG treatment (2 g/kg cumulative dose). More data are needed to clarify appropriate IVIG dosing weight, although based on current published literature, it is recommended to use actual body weight. CONCLUSIONS Data reported support use of IVIG as adjunctive therapy for patients with aHIT. Judicious IVIG use based on key clinical and laboratory findings is critical.
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14
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Gonzales M, Pipalia A, Weil A. Refractory Heparin-Induced Thrombocytopenia With Cerebral Venous Sinus Thrombosis Treated With IVIg, Steroids, and a Combination of Anticoagulants: A Case Report. J Investig Med High Impact Case Rep 2020; 7:2324709619832324. [PMID: 30939936 PMCID: PMC6448115 DOI: 10.1177/2324709619832324] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) type II is caused by antibody production that bind complexes between heparin and platelet factor 4 leading to platelet consumption and thrombosis. In a small subset of cases referred to as autoimmune HIT, the antibodies activate platelets even in the absence of heparin. Refractory HIT is a type of autoimmune HIT in which thrombocytopenia persists for weeks after heparin discontinuation and carries increased risk for thrombosis and more severe thrombocytopenia. We present a case of refractory HIT with cerebral venous sinus thrombosis (CVST) that was successfully treated with a change in anticoagulant alongside steroids and a second trial of intravenous immunoglobulin (IVIg).
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Affiliation(s)
- Mia Gonzales
- 1 East Carolina University, Greenville, NC, USA.,2 Vidant Medical Center, Greenville, NC, USA
| | - Amrish Pipalia
- 1 East Carolina University, Greenville, NC, USA.,2 Vidant Medical Center, Greenville, NC, USA
| | - Andrew Weil
- 1 East Carolina University, Greenville, NC, USA.,2 Vidant Medical Center, Greenville, NC, USA
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15
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Effectiveness of intravenous immunoglobulin use in heparin-induced thrombocytopenia. Blood Coagul Fibrinolysis 2020; 31:287-292. [DOI: 10.1097/mbc.0000000000000918] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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16
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Song JC, Liu SY, Zhu F, Wen AQ, Ma LH, Li WQ, Wu J. Expert consensus on the diagnosis and treatment of thrombocytopenia in adult critical care patients in China. Mil Med Res 2020; 7:15. [PMID: 32241296 PMCID: PMC7118900 DOI: 10.1186/s40779-020-00244-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/20/2020] [Indexed: 01/14/2023] Open
Abstract
Thrombocytopenia is a common complication of critical care patients. The rates of bleeding events and mortality are also significantly increased in critical care patients with thrombocytopenia. Therefore, the Critical Care Medicine Committee of Chinese People's Liberation Army (PLA) worked with Chinese Society of Laboratory Medicine, Chinese Medical Association to develop this consensus to provide guidance for clinical practice. The consensus includes five sections and 27 items: the definition of thrombocytopenia, etiology and pathophysiology, diagnosis and differential diagnosis, treatment and prevention.
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Affiliation(s)
- Jing-Chun Song
- Department of Critical Care Medicine, the 908th Hospital of Joint Logistics Support Forces of Chinese PLA, Nanchang, 360104, China.
| | - Shu-Yuan Liu
- Emergency Department, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Feng Zhu
- Burns and Trauma ICU, Changhai Hospital, Naval Medical University, Shanghai, 200003, China
| | - Ai-Qing Wen
- Department of Blood Transfusion, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Lin-Hao Ma
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Wei-Qin Li
- Surgery Intensive Care Unit, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China.
| | - Jun Wu
- Department of Clinical Laboratory, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, 100035, China.
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17
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Hogan M, Berger JS. Heparin-induced thrombocytopenia (HIT): Review of incidence, diagnosis, and management. Vasc Med 2020; 25:160-173. [PMID: 32195628 DOI: 10.1177/1358863x19898253] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. Here, we review the pathogenesis, incidence, diagnosis, and management of HIT. The first step in thwarting devastating complications from this entity is to maintain a high index of clinical suspicion, followed by an accurate clinical scoring assessment using the 4Ts. Next, appropriate stepwise laboratory testing must be undertaken in order to rule out HIT or establish the diagnosis. In the interim, all heparin must be stopped immediately, and the patient administered alternative anticoagulation. Here we review alternative anticoagulation choice, therapy alternatives in the difficult-to-manage patient with HIT, and the problem of overdiagnosis.
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Affiliation(s)
- Marie Hogan
- Department of Pediatrics, Division of Hematology Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology and Hematology, New York University School of Medicine, New York, NY, USA
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18
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Roberge G, Tritschler T, MacGillivray C, Dufresne L, Nagpal SK, Scarvelis D. Persisting autoimmune heparin-induced thrombocytopenia after elective abdominal aortic aneurysm repair: a case report. J Thromb Thrombolysis 2020; 50:674-677. [DOI: 10.1007/s11239-020-02062-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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19
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Kalpatthi R, Kiss JE. Thrombotic Thrombocytopenic Purpura, Heparin-Induced Thrombocytopenia, and Disseminated Intravascular Coagulation. Crit Care Clin 2020; 36:357-377. [PMID: 32172818 DOI: 10.1016/j.ccc.2019.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hemostatic abnormalities are common among critically ill patients and are associated with a high risk of bleeding. The abnormalities range from isolated thrombocytopenia or prolongation of global coagulation assays to complex disease states, such as thrombotic microangiopathic syndromes, and can be associated with a wide range of conditions, including trauma, surgery, acute disease processes, cardiopulmonary bypass, and exposure to drugs and blood products. Prompt identification of underlying causes is important because treatment strategies vary. Moreover, prompt initiation of both supportive and specific treatments is vital to decrease the morbidity and mortality in the intensive care unit.
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Affiliation(s)
- Ram Kalpatthi
- Division of Pediatric Hematology Oncology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 501A, Pittsburgh, PA 15224, USA
| | - Joseph E Kiss
- Division of Hematology Oncology, Department of Medicine, Clinical Apheresis and Blood Services, Vitalant Northeast Division, University of Pittsburgh School of Medicine, 3636 Boulevard of the Allies, Pittsburgh, PA 15213, USA.
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20
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Inpatient management strategies in a severe case of heparin-induced thrombocytopenia. Transfus Apher Sci 2019; 58:525-528. [DOI: 10.1016/j.transci.2019.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/26/2019] [Accepted: 06/03/2019] [Indexed: 01/25/2023]
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21
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Warkentin TE. High-dose intravenous immunoglobulin for the treatment and prevention of heparin-induced thrombocytopenia: a review. Expert Rev Hematol 2019; 12:685-698. [DOI: 10.1080/17474086.2019.1636645] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
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22
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Bakchoul T, Borst O, Riessen R, Lucic J, Gawaz M, Althaus K, Aidery P. Autoimmune Heparin-Induced Thrombocytopenia after Transcatheter Aortic Valve Implantation: Successful Treatment with Adjunct High-Dose Intravenous Immunoglobulin. TH OPEN 2019; 3:e200-e202. [PMID: 31263800 PMCID: PMC6599067 DOI: 10.1055/s-0039-1692990] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 05/22/2019] [Indexed: 01/30/2023] Open
Abstract
We describe a rare case of autoimmune heparin-induced thrombocytopenia after transcatheter aortic valve implantation in which antibodies against platelet factor 4/heparin have led to platelet activation even after heparin cessation, causing a delayed drop in platelet count to below 20 × 10
9
/L. Most interestingly, platelet count rapidly improved after intravenous immunoglobulin treatment and no new thromboembolic complications were observed with further anticoagulation with rivaroxaban.
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Affiliation(s)
- Tamam Bakchoul
- Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Oliver Borst
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Reimer Riessen
- Department of Internal Medicine, Medical Intensive Care Unit, University of Tübingen, Tübingen, Germany
| | - Josip Lucic
- Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Karina Althaus
- Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Parwez Aidery
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
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23
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Mohanty E, Nazir S, Sheppard JAI, Forman DA, Warkentin TE. High-dose intravenous immunoglobulin to treat spontaneous heparin-induced thrombocytopenia syndrome. J Thromb Haemost 2019; 17:841-844. [PMID: 30773806 DOI: 10.1111/jth.14411] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Indexed: 01/28/2023]
Abstract
Essentials Spontaneous HIT syndrome clinically/serologically resembles HIT but without proximate heparin. Rarely, spontaneous HIT syndrome complicates total knee arthroplasty surgery. Mesenteric vein thrombosis is a rare presentation of spontaneous HIT syndrome. IVIg rapidly corrects thrombocytopenia by inhibiting heparin-independent platelet activation. SUMMARY: Spontaneous heparin-induced thrombocytopenia (HIT) syndrome is an autoimmune HIT (aHIT) disorder characterized by thrombocytopenia, thrombosis, and HIT antibodies despite no proximate heparin exposure. For unknown reasons, many cases occur after total knee arthroplasty. A 52-year-old woman presented 12 days posttotal knee replacement (aspirin thromboprophylaxis) with gastrointestinal bleeding (superior mesenteric vein thrombosis); the platelet count was 63 × 109 L-1 . After bowel resection and a brief course of heparin, treatment was changed to argatroban followed by fondaparinux. In addition, high-dose intravenous immunoglobulin (IVIg), 1 g kg-1 on 2 consecutive days, resulted in abrupt platelet count rise from 21 (nadir) pre-IVIg to 137 (post-IVIg), and 2 days later to 200 × 109 L-1 . Heparin-independent serum-induced serotonin-release abruptly decreased from 91% (pre-IVIg) to 14% (post-IVIg); although serotonin-release later rebounded to 49%, the patient's platelet counts remained normal. Our observations support the emerging concept that high-dose IVIg is effective for treating aHIT disorders, including spontaneous HIT syndrome.
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Affiliation(s)
| | - Salik Nazir
- Reading Health System, West Reading, PA, USA
| | - Jo-Ann I Sheppard
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
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24
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Arcinas LA, Manji RA, Hrymak C, Dao V, Sheppard JAI, Warkentin TE. Autoimmune heparin-induced thrombocytopenia and venous limb gangrene after aortic dissection repair: in vitro and in vivo effects of intravenous immunoglobulin. Transfusion 2019; 59:1924-1933. [PMID: 30903805 DOI: 10.1111/trf.15263] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/19/2019] [Accepted: 02/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a prothrombotic disorder characterized by heparin-dependent antibodies that activate platelets (PLTs) via PLT FcγIIa receptors. "Autoimmune" HIT (aHIT) indicates a HIT subset where thrombocytopenia progresses or persists despite stopping heparin; aHIT sera activate PLTs strongly even in the absence of heparin (heparin-independent PLT-activating properties). Affected patients are at risk of severe complications, including dual macro- and microvascular thrombosis leading to venous limb gangrene. High-dose intravenous immunoglobulin (IVIG) offers an approach to interrupt heparin-independent PLT-activating effects of aHIT antibodies. CASE REPORT A 78-year-old male who underwent cardiopulmonary bypass for aortic dissection developed aHIT, disseminated intravascular coagulation, and deep vein thrombosis; progression to venous limb gangrene occurred during partial thromboplastin time (PTT)-adjusted bivalirudin infusion (underdosing from "PTT confounding"). Thrombocytopenia recovered with high-dose IVIG, although the PLT count increase began only after the third dose of a 5-day IVIG regimen (0.4 g/kg/day × 5 days). We reviewed case reports and case series of IVIG for treating HIT, focusing on various IVIG dosing regimens used. RESULTS Patient serum-induced PLT activation was inhibited in vitro by IVIG in a dose-dependent fashion; inhibition of PLT activation by IVIG was much more marked in the absence of heparin versus the presence of heparin (0.2 U/mL). Our literature review indicated 1 g/kg × 2 IVIG dosing as most common for treating HIT, usually associated with rapid PLT count recovery. CONCLUSION Our clinical and laboratory observations support dose-dependent efficacy of IVIG for decreasing PLT activation and thus correcting thrombocytopenia in aHIT. Our case experience and literature review suggests dosing of 1 g/kg IVIG × 2 for patients with severe aHIT.
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Affiliation(s)
- Liane A Arcinas
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rizwan A Manji
- Section of Cardiac Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.,Section of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carmen Hrymak
- Section of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Vi Dao
- Section of Hematology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jo-Ann I Sheppard
- Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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