COVID-19 vaccine-associated immune thrombosis and thrombocytopenia (VITT): Diagnostic and therapeutic recommendations for a new syndrome

COVID-19 Neuroimaging Update: Pathophysiology, Acute Findings, and Post-Acute Developments

COVID-19 has prominent effects on the nervous system with important manifestations on neuroimaging. In this review, we discuss the neuroimaging appearance of acute COVID-19 that became evident during the early stages of the pandemic. We highlight the underlying pathophysiology mediating nervous system effects and neuroimaging appearances including systemic inflammatory response such as cytokine storm, coagulopathy, and para/post-infections immune mediated phenomena. We also discuss the nervous system manifestations of COVID-19 and the role of imaging as the pandemic has evolved over time, including related to the development of vaccines and the emergence of post-acute sequalae such as long COVID.

Anti-PF4 antibodies and their relationship with COVID infection

Detecting anti-PF4 antibodies remains the golden diagnostic method for heparin-induced thrombocytopenia (HIT) diagnosis with high sensitivity and specificity. Various lab tests detect anti-PF4 antibodies, including immunoassays and functional assays. Even with positive detection of the anti-PF4 antibody, several factors are involved in the result. The concept of anti-PF4 disorders was recently brought to light during the COVID pandemic since the development of vaccine-induced thrombotic thrombocytopenia (VITT) with the adenovirus-vectored-DNA vaccine during the pandemic. Circumstances that detect anti-PF4 antibodies are classified as anti-PF4 disorders, including VITT, autoimmune HIT and spontaneous HIT. Some studies showed a higher percentage of anti-PF4 antibody detection among the population infected by COVID-19 without heparin exposure and some supported the theory that the anti-PF4 antibodies were related to the disease severity. In this review article, we provide a brief review of anti-PF4 disorders and summarize the current studies of anti-PF4 antibodies and COVID-19 infection.

Superior mesenteric vein thrombosis due to COVID-19 vaccination: a case report

BACKGROUND

The worldwide vaccination response to COVID-19 has been associated with rare thrombotic complications, including the case of postvaccination splanchnic venous thrombosis we report here.

CASE PRESENTATION

An 80-year-old Japanese male with abdominal pain presented to our hospital six days after receiving a dose of the COVID-19 messenger ribonucleic acid vaccine. Abdominal computed tomography showed localized edema of the small intestine, increased density of the surrounding adipose tissue, and a thrombus in the superior mesenteric vein. Conservative inpatient treatment with unfractionated heparin relieved the thrombosis, and the patient is currently receiving oral apixaban as an outpatient.

CONCLUSION

Reported cases of thrombosis after COVID-19 vaccination typically have been associated with viral vector vaccines, with few reports of thrombosis induced by mRNA vaccines. The potential for venous thrombosis should be explored when patients present with abdominal pain soon after COVID-19 vaccination.

Cardiac Complications and COVID-19: A Review of Life-threatening Co-morbidities

The novel 2019 coronavirus disease (COVID-19) was first reported in the last days of December 2019 in Wuhan, China. The presence of certain co-morbidities, including cardiovascular diseases (CVDs), are the basis for worse outcomes in patients with COVID-19. Relevant English-language literature was searched and retrieved from the Google Scholar search engine and PubMed database up to 2023 using COVID-19, SARS-CoV-2, Heart failure, Myocardial infarction, and Arrhythmia and Cardiac complication as keywords. Increased hemodynamic load, ischemia-related dysfunction, ventricular remodeling, excessive neurohumoral stimulation, abnormal myocyte calcium cycling, and excessive or insufficient extracellular matrix proliferation are associated with heart failure (HF) in COVID-19 patients. Inflammatory reaction due to the excessive release of inflammatory cytokines, leads to myocardial infarction (MI) in these patients. The virus can induce heart arrhythmia through cardiac complications, hypoxia, decreased heart hemodynamics, and remarkable inflammatory markers. Moreover, studies have linked cardiac complications in COVID-19 with poor outcomes, extended hospitalization time, and increased mortality rate. Patients with COVID-19 and CVDs are at higher mortality risk and they should be given high priority when receiving the treatment and intensive care during hospitalization.

Blood Coagulation and Thrombotic Disorders following SARS-CoV-2 Infection and COVID-19 Vaccination

Although abundant data confirm the efficacy and safety profile of the developed vaccines against COVID-19, there are still some concerns regarding vaccination in high-risk populations. This is especially valid for patients susceptible to thrombotic or bleeding events and hesitant people due to the fear of thrombotic incidents following vaccination. This narrative review focuses on various inherited and acquired thrombotic and coagulation disorders and the possible pathophysiologic mechanisms interacting with the coagulation system during immunization in view of the currently available safety data regarding COVID-19 vaccines. Inherited blood coagulation disorders and inherited thrombotic disorders in the light of COVID-19, as well as blood coagulation and thrombotic disorders and bleeding complications following COVID-19 vaccines, along with the possible pathogenesis hypotheses, therapeutic interventions, and imaging for diagnosing are discussed in detail. Lastly, the lack of causality between the bleeding and thrombotic events and COVID-19 vaccines is debated, but still emphasizes the importance of vaccination against COVID-19, outweighing the minimal risk of potential rare adverse events associated with coagulation.

Prolonged headache with vaccine- and dose-specific headache pattern associated with vaccine against SARS-CoV-2 in patients with migraine

OBJECTIVE

To examine SARS-CoV-2 vaccine-related headache characteristics and risk factors in migraine patients.

METHODS

This retrospective cohort study included 732 migraine patients who had AstraZeneca Vaxzevria, Pfizer-BioNTech Comirnaty, or Moderna Spikevax vaccines. Participants provided information through questionnaires and headache diaries. Headache frequency before and after vaccination and factors associated with headache risk were examined.

RESULTS

Approximately a third of patients reported increased headache the day after having primary and booster doses, with mean increase ± SD of 1.9 ± 1.2 and 1.8 ± 1.1 days/week, respectively. Proportions of migraine patients with headache (after vaccination vs. before vaccination) increased after having primary-dose Vaxzevria (35.3% vs. 22.8%, p < 0.001) but not Spikevax (23.8% vs. 26.7%, p = 0.700) or Comirnaty (33.2% vs. 25.8%, p = 0.058). Headache proportion increased after having all three boosters (Vaxzevria 27.1% vs. 17.9% p = 0.003; Comirnaty 34.1% vs. 24.5% p = 0.009; Spikevax 35.2% vs. 24.8% p = 0.031). For primary dose with Vaxzevria and Comirnaty, headache risk increased on the vaccination day, peaked on the day after vaccination, and subsided within a week, while for Spikevax headache risk rose gradually after vaccination, peaked on the seventh post-vaccination day and subsided subsequently. For booster dose, headache risk generally increased on the vaccination day, peaked on the day after vaccination, and subsided gradually with fluctuating pattern within a month. Our study also showed that headache increased on the day before primary dose but not booster dose vaccination and it may be attributable to stress associated with having to undertake new vaccines. Multivariable analyses showed that depression was associated with headache.

CONCLUSION

Prolonged headache with vaccine- and dose-specific headache pattern was found. Patients with higher risks of vaccine-related headache must be informed of the potential worsening headache.

Changes in Students' Perceptions Regarding Adolescent Vaccinations through a Before-After Study Conducted during the COVID-19 Pandemic: GIRASOLE Project Study

The COVID-19 pandemic caused a reduction in vaccination coverage for all age groups, especially in non-infant age. The main objective of the present study is to evaluate the effectiveness of an online intervention conducted among adolescents during the COVID-19 pandemic in increasing knowledge and positive attitudes toward vaccinations. The study, which took place online from March to May 2021, involved 267 students from six lower secondary schools in Palermo city (Italy); they filled out the questionnaire before and after the intervention. The questionnaire was based on the protection motivation theory (PMT), which estimates the improvement in vaccination-related knowledge and attitudes. The pre- and post-intervention comparison showed a significant increase in the perception of the disease severity: strongly agree pre-intervention n = 150 (58.6%) and post-intervention n = 173 (67.6%, p < 0.001), rated on a five-point Likert scale. In a multivariate analysis, the factor associated with the improvement in the score after the intervention was the school dropout index (low vs. very high dropout index OR 4.5; p < 0.03). The educational intervention was more effective in schools with lower early school leaving rates, an indirect index of socio-economic status. The topic of vaccination has caught the adolescents' attention, it is, therefore, important that interventions tackling teenagers are tailored to reduce their emotional tension about the perception of adverse effects and improve vaccination coverage.

"Vitreous Hemorrhage and Long-Lasting Priapism After COVID-19 m-RNA Based Vaccine: A Case Report"

PURPOSE

To report a case of possible multi-district thromboembolic event involving the eye of a patient with several cardiovascular risk factors, following a second inoculation of SARS-CoV-2 m-RNA based vaccine.

CASE-REPORT

A 60-year-old man presented with blurred vision in the left eye lasting 1 month but started within 24 hours from the 2nd dose of BNT162b2 vaccine inoculation. He also reported a long-lasting but self-limiting priapism which started about 4 h after the vaccination. Patient's medical history included: acute lymphoblastic leukemia, treated with chemotherapy and HLA-identical sibling donor transplant 18 months earlier; subsequent cytomegalovirus posterior outer retinal necrosis (PORN) resolved with antiviral treatment; type II diabetes and erectile dysfunction. Ocular examination of the affected eye revealed vitreous hemorrhage which limited the observation of details of the fundus. After a 2-week follow-up without any clinical improvement, parsplana vitrectomy (PPV) with cataract extraction was performed. Surgical aspiration of a large preretinal hemorrhage revealed intraretinal flame-shaped hemorrhages and some cotton wool spots. Further intraoperative examination and post-operative fluorescein angiography excluded the rhegmatogenaous and the neovascular origin of the intraocular bleeding.

CONCLUSIONS

Due to the several predisposing factors such as diabetes, aspirin assumption, history of blood dyscrasia and infectious retinitis, the relationship between the acute intraocular bleeding and the BNT162b2 inoculation remains difficult to ascertain in this patient. However, the occurrence of lasting priapism and vitreous hemorrhage within 24 h from the vaccination is a critical event which deserves to be mentioned.

Covishield vaccination and pulmonary thromboembolism: A coincidence or a causal association?

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.

Acquired hemophilia A (AHA) due to anti-SARS-CoV-2 vaccination: A systematic review

Vaccination against SARS-CoV2 has been the largest vaccination campaign over the past two decades. The aim of this study is to qualitatively assess the reported cases of acquired hemophilia A (AHA) that developed after COVID-19 vaccination to further elaborate on incidence, presentation, treatment, and outcomes.We queried Medline (PubMed), Google Scholar, and Embase databases to find reported cases of AHA after COVID-19 vaccines. We found 14 studies (19 cases) for this descriptive analysis. Most patients were elderly (mean age 73 years) and males (n = 12) with multiple comorbidities. All cases developed after mRNA vaccines - BNT162b2 Pfizer-BioNTech (n = 13) and mRNA-1273 Moderna (n = 6). All except one patient were treated, with the most common therapy being a combination of steroids, immunosuppression, and rFVIII (n = 13). Two patients died due to acute respiratory distress, and gall bladder rupture with persistent bleeding, respectively. While evaluating a patient with bleeding diathesis after COVID-19 vaccination, AHA should be kept in the differential diagnosis. Given the low incidence, we believe that the benefit of vaccination still outweighs the risk of disease acquisition.

How to approach acute thrombosis and thrombocytopenia

Acute thrombosis and thrombocytopenia pose challenges to the clinician. Thrombocytopenia is naturally viewed as a risk factor for bleeding, and an association with acute thrombosis appears paradoxical. It presents typically as a medical emergency and requires treatment to be started before having confirmatory results. This review supports the attending clinician to recognise and manage conditions that are part of the thrombotic thrombocytopenic syndrome through four illustrative clinical cases. Common themes linking the underlying pathology and treatment are explored to highlight the continued relevance of this rare, but often devastating, presentation.

Molecular Mimicry of the Viral Spike in the SARS-CoV-2 Vaccine Possibly Triggers Transient Dysregulation of ACE2, Leading to Vascular and Coagulation Dysfunction Similar to SARS-CoV-2 Infection

The benefits of SARS-CoV-2 spike mRNA vaccines are well known, including a significant decline in COVID-19 morbidity and a decrease in the mortality rate of SARS-CoV-2 infected persons. However, pharmacovigilance studies have revealed the existence of rare cases of cardiovascular complications after mass vaccination using such formulations. Cases of high blood pressure have also been reported but were rarely documented under perfectly controlled medical supervision. The press release of these warning signals triggered a huge debate over COVID-19 vaccines' safety. Thereby, our attention was quickly focused on issues involving the risk of myocarditis, acute coronary syndrome, hypertension and thrombosis. Rare cases of undesirable post-vaccine pathophysiological phenomena should question us, especially when they occur in young subjects. They are more likely to occur with inappropriate use of mRNA vaccine (e.g., at the time when the immune response is already very active during a low-noise infection in the process of healing), leading to angiotensin II (Ang II) induced inflammation triggering tissue damage. Such harmful effects observed after the COVID-19 vaccine evoke a possible molecular mimicry of the viral spike transiently dysregulating angiotensin converting enzyme 2 (ACE2) function. Although the benefit/risk ratio of SARS-CoV-2 spike mRNA vaccine is very favorable, it seems reasonable to suggest medical surveillance to patients with a history of cardiovascular diseases who receive the COVID-19 vaccine.

A case report overlapped vaccine and COVID-19 in disseminated atherosclerosis

Coronavirus disease 2019 (COVID-19) has become a part of our lives now and we have no more effective way of coping than a vaccine. COVID-19 is a disease that causes severe thrombosis outside the respiratory tract. Vaccines also protect us in this respect, but in some rare cases, thrombosis has been found to develop after vaccination (much less frequently than COVID-19). What was interesting in our case was that it showed how a disaster could happen under three factors that predispose to thrombosis. A 65-year-old female patient with disseminated atherosclerosis was admitted to the intensive care unit with complaints of dyspnea and dysphasia. In the evening of the day, the patient had the vaccination 2 weeks ago, she had active COVID-19. On examination, lower extremity pulses could not be detected. The patient's imaging and blood tests were performed. Multiple complications such as embolic stroke, venous and arterial thrombosis, pulmonary embolism, and pericarditis were observed in the patient. This case may give consideration to anticoagulant therapy studies. We give effective anticoagulant therapy in the presence of COVID-19 in patients at risk of thrombosis. Can anticoagulant therapy be considered after vaccination in patients at risk of thrombosis such as disseminated atherosclerosis?

Thrombosis of the deep dorsal vein of the penis caused by vaccine-induced thrombotic thrombocytopenia: First reported case

The first described case of deep dorsal vein thrombosis of the penis secondary to vaccine-induced thrombotic thrombocytopenia (VITT), a complication of COVID adenoviral vector vaccines. The patient reported pain in the penis one month after vaccination. On ultrasound, a deep dorsal vein thrombosis was found and a biological workup was ordered to confirm the VITT trail. Anticoagulant therapy was immediately initiated and the patient responds well while suffering from erectile dysfunction. VITT is a potentially serious event that can be life-threatening; every practitioner should know how to deal with it.

The COVID-19 vaccine did not affect the basal immune response and menstruation in female athletes

The COVID-19 pandemic restricted the regular training and competition program of athletes. Vaccines against COVID-19 are known to be beneficial for the disease; however, the unknown side effects of vaccines and postvaccination reactions have made some athletes hesitant to get vaccinated. We investigated the changes in inflammatory responses and menstrual cycles of female athletes before and after vaccination. Twenty female athletes were enrolled in this study. Blood was collected from each subject before the first COVID-19 vaccination and after the first and second vaccinations. Laboratory data, including white blood cell, neutrophil, lymphocyte, and platelet counts, and inflammatory markers, including NLR (neutrophil-to-lymphocyte ratio), PLR (platelet lymphocyte ratio), RPR (red cell distribution width to platelet ratio), SII (systemic immune-inflammation index), and NeuPla (neutrophil-platelet ratio), were analyzed statistically. The menstrual changes before and after vaccination and the side effects were collected by questionnaires. No significant changes in the laboratory data were found after the first and second shots when compared to those at prevaccination: white blood cell, neutrophil, lymphocyte, platelet, NLR, PLR, SII, RPR, and NeuPla (p > 0.05). In addition, there were no significant changes in the menstruation cycle or days of the menstrual period (p > 0.05). All side effects after vaccination were mild and subsided in 2 days. The blood cell counts, inflammatory markers, and menstruation of female athletes were not affected by COVID-19 vaccines.

Investigating a Signal of Acquired Hemophilia Associated with COVID-19 Vaccination: A Systematic Case Review

Acquired hemophilia A (AHA), a rare but life-threatening disorder, most commonly occurs in older people and during pregnancy. During the coronavirus disease 2019 (COVID-19) vaccination campaign, an unexpected number of newly diagnosed AHA patients have been identified in clinical practice that were temporally related to COVID-19 vaccination. We present the result of a signal detection analysis aimed at exploring a possible association between COVID-19 immunization and occurrence of AHA. A disproportionality analysis on the World Health Organization (WHO) database was performed to investigate the presence of a signal of risk for AHA associated with COVID-19 vaccines. Reports of AHA associated with any COVID-19 vaccine included in the WHO database were then integrated with those available on the Food and Drug Administration Vaccine Adverse Events Reporting System and those published in the medical literature. The WHO database included 146 reports of AHA. The information component (IC) was significant for the association of AHA with all COVID-19 vaccines (IC025: 1.1) and with the vaccine product BNT162b2 (IC025: 1.6). After duplicate exclusion, 96 unique cases of AHA following COVID-19 vaccines have been reviewed. Median time to diagnosis was 18 days and 40% of cases documented the occurrence after the second dose. Overall, in 57% of the investigated cases, a preexisting condition predisposing to AHA was excluded. About 22% of cases occurred in subjects with age ≤65 years and there was no case associated with pregnancy. Mortality was 11%. Although we cannot exclude that the unexpected frequency of AHA diagnosis can be explained by a detection bias, the signal for COVID-19 vaccine-related AHA is robust and deserves further investigations.

Vaccine-induced immune thrombotic thrombocytopenia (VITT) after SARS-CoV-2 vaccination: Two cases from Germany with unusual presentation

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare clinical condition that has emerged during the mass immunization against SARS-CoV-2. Reports indicate that VITT may also be induced by other vaccines, such as the human papillomavirus vaccine, or occur independently of vaccination. Its recognition requires a high index of suspicion, especially in patients presenting with thrombocytopenia and thrombosis several days after vaccination with an adenoviral vector-based vaccine against SARS-CoV-2. Bleeding manifestations do not exclude VITT, as initially assumed. It is of great importance to perform the appropriate diagnostic tests early in the course of the disease, as false-negative results may occur and many aspects of VITT are not fully understood. These two cases from Germany demonstrate unusual presentations of VITT.

COVID-19 Vaccination and Alcohol Consumption: Justification of Risks

Since the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, pharmaceutical companies and research institutions have been actively working to develop vaccines, and the mass roll-out of vaccinations against COVID-19 began in January 2021. At the same time, during lockdowns, the consumption of alcoholic beverages increased. During the peak of vaccination, consumption remained at high levels around the world, despite the gradual relaxation of quarantine restrictions. Two of the popular queries on search engines were whether it is safe to drink alcohol after vaccination and whether this will affect the effectiveness of vaccines. Over the past two years, many studies have been published suggesting that excessive drinking not only worsens the course of an acute respiratory distress syndrome caused by the SARS-CoV-2 virus but can also exacerbate post-COVID-19 syndrome. Despite all sorts of online speculation, there is no specific scientific data on alcohol-induced complications after vaccination in the literature. Most of the published vaccine clinical trials do not include groups of patients with a history of alcohol-use disorders. This review analyzed the well-known and new mechanisms of action of COVID-19 vaccines on the immune system and the effects of alcohol and its metabolites on these mechanisms.

[Neurological complications after covid-19 vaccination]

The aim of our work was to study the relevance and incidence of neurological post-vaccination complications during the COVID-19 pandemic. Based on the results of a systematic literature search of several databases, the current review describes the diagnosed complications, including neurological, that occurred after the administration of the COVID-19 vaccine during the pandemic period. To fully establish the pathophysiological mechanisms of the development of a causal relationship of neurological complications with vaccines against COVID-19, it becomes necessary to continue long-term studies. This will make it possible to carry out a pharmacological correction of the quality of vaccine safety.

An intervention study through education: The change in attitudes and knowledge of educators about the COVID-19 vaccine

BACKGROUND

Reliable and culturally informed health communication is vital in developing positive health behaviors.

OBJECTIVE

The aim of this study was to investigate the change in knowledge and attitudes about COVID-19 vaccines by providing training to educators in a province in the east of Turkey.

METHODS

A questionnaire developed by the researchers on the basis of the literature was used in this intervention study. It consisted of three parts: socio-demographic information, before education knowledge (BEK) and Attitudes Towards the COVID-19 Vaccine (BEATV), and after education knowledge (AEK) and Attitudes Towards the COVID-19 Vaccine (AEATV). There were 99 teachers, 32 public education teachers, and 144 religious officials who participated in the study. The data were analyzed using SPSS Statistics Pack version 22.0 (IBM, Armonk, NY, USA). Statistical significance value was accepted as p < 0.05.

RESULTS

Among the participants, the number of correct answers to all questions increased as a result of the study. There was a positive increase in most of the ATV items after the training.

CONCLUSION

Education on COVID-19 vaccines increased awareness as shown by the total number of correct answers and the improved attitude of educators.

Lupus anticoagulant activity and thrombosis post COVID-19 vaccination

Some reports have discussed the development of a new entity called vaccine-induced immune thrombotic thrombocytopenia after COVID-19 vaccination. In this case series, we are describing four patients who have developed lupus anticoagulant-associated venous thromboembolism after Pfizer mRNA COVID-19 vaccination. All were COVID-19 negative on admission. Three had developed thrombosis after the first dose and one after the second dose of vaccination. All of them had venous thrombosis. Three patients developed thrombosis 2 weeks after vaccination and the fourth patient had developed thrombosis after 3 weeks of vaccination. None of the patients had thrombocytopenia on or during admission as seen in the case of vaccine-induced immune thrombotic thrombocytopenia. All patients had positive lupus anticoagulant and negative anticardiolipin antibodies and antibeta2 glycoprotein I. All of them were stable on discharge and were treated with low molecular weight heparin followed by warfarin. We suggest the presence of a possible link between the development of antiphospholipid antibodies and COVID-19 vaccine that requires further assessment.

Immunogenetic Predisposition to SARS-CoV-2 Infection

Herein, we included 527 individuals from two Hospitals, Chemnitz and University-Hospital Leipzig. In total, 199 were negative for PCR and 328 were positive upon first admission. We used next generation sequencing for HLA-A, B, C, DRB1, DRB345, DQA1, DQB1, DPA1, and DPB1, and in some cases, HLA-E, F, G, and H. Furthermore, we molecularly defined 22 blood group systems comprising 26 genes and 5 platelet antigen genes. We observed a significant enrichment of homozygosity for DQA/DQB in the positive group. Within the negative subjects, HLA-B*57:01, HLA-B*55:01, DRB1*13:01, and DRB1*01:01 were enriched, and in the positive group, homozygosity for DQA/DQB, DRB1*09:01, and DRB1*15:01 was observed. DQA1*01:01, DQA1*02:01, and DQA1*01:03 were enriched in the negative group. HLA-DQB1*06:02 was enriched in the positive group, and HLA-DQB1*05:01 and HLA-DQB1*06:03 were enriched in the negative group. For the blood group systems MNS, RH, LE, FY, JK, YT, DO, and KN, enrichment was seen in both groups, depending on the antigen under observation. Homozygosity for D-positive RHD alleles, as well as the phenotypes M-N+ of the MNS blood group system and Yk(a-) of the KN system, were enriched in the positive group. All of these significances disappeared upon correction. Subjects who carried homozygous HPA-1a were more frequent in the negative group, contrasting with the finding that HPA-1ab was enriched in the positive group.

High Seroprevalence of Anti-SARS-CoV-2 IgM/IgG among Inhabitants of Sakaka City, Aljouf, Saudi Arabia

(1) Backgrounds and Objectives: The global battle to contain the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) is still ongoing. This cross-sectional study aimed to detect the seroprevalence of anti-SARS-CoV-2 IgM/IgG among previously symptomatic/asymptomatic and vaccinated/unvaccinated inhabitants of Sakaka City, Aljouf, Saudi Arabia. (2) Methods: Blood samples of 400 participants were tested for the presence of anti-SARS-CoV-2 IgM/IgG using colloidal gold immuno-chromatography lateral flow immunoassay cards. (3) Results: The prevalence of anti-SARS-CoV-2 IgM and IgG positivity was 45.8% and 42.3%, respectively. Statistically significant correlations (p < 0.05) were found between the previous RT-PCR testing for SARS-CoV-2-RNA and positivity for IgM and/or IgG. The highest seroprevalence of IgM and IgG were detected among smokers, participants aged ≥40 years, and patients with chronic diseases. Although most of the participants (58.5%) did not previously experience COVID-19 like symptoms, the anti-SARS-CoV-2 IgM and IgG seropositivity amongst them was 49.1% and 25.6%, respectively, with higher seroprevalence among males than females. At the time of the study, the SARS-CoV-2 vaccination rate at our locality in Saudi Arabia was 43.8% with statistically significant correlation (p < 0.001) between being vaccinated and anti-SARS-CoV-2 IgM and/or IgG positivity, with more positivity after receiving the second vaccine dose. (4) Conclusions: Public assessment reflects the real scale of the disease exposure among the community and helps in identifying the asymptomatic carriers that constitute a major problem for controlling the SARS-CoV-2. To limit the spread of the virus, rigorous implementation of large-scale SARS-CoV-2 vaccination and anti-SARS-CoV-2 serological testing strategies should be empowered.

Lower limb arterial thrombosis followed by sub-massive pulmonary thromboembolism after Sinopharm BBIBP-CorV COVID-19 vaccination

The global COVID-19 vaccination had an undeniable influence on the pandemic management, despite of having reported rare but life-threatening side-effects of vaccines. Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare autoimmune complication determined by thrombocytopenia and thrombosis propensity in the circulatory system. The activation of antibodies against platelet factor-4 (PF-4) which mimics the heparin-induced thrombocytopenia (HIT) characteristic is the main known pathogenicity of the disease. Herein, we reported a case of VITT in a middle-aged woman with no previous history of thrombophilia or other medical conditions who presented with thrombosis of the left superficial femoral artery 3-days after receiving the second dose of inactivated BBIBP-CorV (Sinopharm) vaccine. The patient underwent bypass vascular surgery and received none-heparin anticoagulation consistent with high-dose intravenous immunoglobin. Eight days after the discharge, she was subsequently referred to our center with the presentation of sub-massive pulmonary thromboembolism in spite of receiving the prophylactic anticoagulants during follow-up period. Details on side-effects of COVID-19 vaccines, specifically the inactivated ones are yet to be fully ascertained. Clinicians should consider the history of COVID-19 vaccines in thromboembolism patients who do not have well-acknowledged risk factors. Further studies about the necessity of prophylactic anticoagulants and clinical judgment for receiving other vaccines in such patients are required.

COVID-19 Vaccines, Effectiveness, and Immune Responses

The COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has captivated the globe's attention since its emergence in 2019. This highly infectious, spreadable, and dangerous pathogen has caused health, social, and economic crises. Therefore, a worldwide collaborative effort was made to find an efficient strategy to overcome and develop vaccines. The new vaccines provide an effective immune response that safeguards the community from the virus' severity. WHO has approved nine vaccines for emergency use based on safety and efficacy data collected from various conducted clinical trials. Herein, we review the safety and effectiveness of the WHO-approved COVID-19 vaccines and associated immune responses, and their impact on improving the public's health. Several immunological studies have demonstrated that vaccination dramatically enhances the immune response and reduces the likelihood of future infections in previously infected individuals. However, the type of vaccination and individual health status can significantly affect immune responses. Exposure of healthy individuals to adenovirus vectors or mRNA vaccines causes the early production of antibodies from B and T cells. On the other hand, unhealthy individuals were more likely to experience harmful events due to relapses in their existing conditions. Taken together, aligning with the proper vaccination to a patient's case can result in better outcomes.

Cerebral venous sinus thrombosis after COVID-19 vaccination and congenital deficiency of coagulation factors: Is there a correlation?

In January 2020, SARS-COV-2 infection spread worldwide and was declared "pandemic" by WHO. Because of the high contagiousness of the virus and devastating effects of the epidemic on public health, numerous efforts have been made to develop suitable vaccines to prevent the infection. Among the side effects developed by patients who undergone vaccination, there are common symptoms but also more serious reactions such as the thrombosis syndromes. This paper presents two cases of thrombosis temporally associated with live-vectored Covid vaccination similar to vaccine-induced thrombocytopenia (VITT) in patients with inherited thrombophilia (respectively, the deficiency of protein S and a Factor II mutation). The clinical manifestation caused by VITT is characterized by widespread thrombosis especially affecting intracranial venous sinus, which may cause massive bleeding and intracranial hemorrhage. Although this condition is widely described in literature, there is no evident correlation between this side effect and inherited condition of thrombophilia. The authors suggest that the presence of inherited thrombophilia should be better investigated and, if necessary, screened during the anamnestic data collection before the vaccine administration, leading the healthcare professional to choose the appropriate vaccine to the patient.

Severe Thrombocytopenia, Thrombosis and Anti-PF4 Antibody after Pfizer-BioNTech COVID-19 mRNA Vaccine Booster-Is It Vaccine-Induced Immune Thrombotic Thrombocytopenia?

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a serious and life-threatening complication occurring after adenovirus-vector COVID-19 vaccines, and is rarely reported after other vaccine types. Herein, we report a case of possible VITT after the Pfizer-BioNTech mRNA vaccine booster, who presented with extensive lower limb deep vein thrombosis, severe thrombocytopenia, markedly elevated D-dimer and positive anti-PF4 antibody occurring 2 weeks post-vaccination, concurrent with a lupus anticoagulant. A complete recovery was made after intravenous immunoglobulin, prednisolone and anticoagulation with the oral direct Xa inhibitor rivaroxaban. The presenting features of VITT may overlap with those of antiphospholipid syndrome associated with anti-PF4 and immune thrombocytopenia. We discuss the diagnostic considerations in VITT and highlight the challenges of performing VITT confirmatory assays in non-specialized settings. The set of five diagnostic criteria for VITT is a useful tool for guiding initial management, but may potentially include patients without VITT. The bleeding risks of severe thrombocytopenia in the face of thrombosis, requiring anticoagulant therapy, present a clinical challenge, but early recognition and management can potentially lead to favorable outcomes.

Mondor's disease of the breast: A cutaneous thromboembolic manifestation of Covid-19?

BACKGROUND

Mondor's disease is a rare disorder characterised by thrombosis of superficial veins within the subcutaneous tissue of the breast and other organs. While factors such as trauma, infection, physical exertion, breast cancer and breast surgery have been implicated, in the majority no cause is identified.

PATIENTS

Twenty patients presented with a clinical diagnosis of Mondor's disease to the Edinburgh Breast Services in 2020. We present the etiopathogenic data as well as clinical and imaging diagnostic findings.

RESULTS

During 2020, the annual incidence of Mondor's disease, in the UK's largest breast unit, increased five-fold compared to data from the previous year. This variation in the frequency of cases corresponded to trends in the frequency of Covid-19 infection during the pandemic. None of the patients had diagnosed COVID and few had any known etiopathogenic causes for their Mondor's.

CONCLUSION

Several recent studies have provided evidence for links between Covid-19 and thromboembolic events. Isolated reports have proposed a link between Covid-19 and Mondor's disease of the penis. Here we present data on a large series of Mondor's disease of the breast supporting a link between breast Mondor's and Covid-19.

Vaccine-induced immune thrombotic thrombocytopenia: Updates in pathobiology and diagnosis

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.

Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM

There is a wide gap between patients who need transplants and the organs that are available in India. Extending the standard donation criterion is certainly important to address the scarcity of organs for transplantation. Intensivists play a major role in the success of deceased donor organ transplants. Recommendations for deceased donor organ evaluation are not discussed in most intensive care guidelines. The purpose of this position statement is to establish current evidence-based recommendations for multiprofessional critical care staff in the evaluation, assessment, and selection of potential organ donors. These recommendations will give "real-world" criteria that are acceptable in the Indian context. The aim of this set of recommendations is to both increase the number and enhance the quality of transplantable organs.

How to cite this article

Zirpe KG, Tiwari AM, Pandit RA, Govil D, Mishra RC, Samavedam S, et al. Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM. Indian J Crit Care Med 2022;26(S2):S43-S50.

A Single-Centre Experience of Post-COVID-19 Vaccine-Related Immune-Mediated Complications

The significant impact of the COVID-19 pandemic has resulted in a worldwide effort to develop effective vaccines. In the United Kingdom, the COVID-19 vaccine development and roll-out has been overwhelmingly successful in reducing infections and deaths. However, case reports have emerged of a rare syndrome of vaccine-induced immune thrombocytopenia and thrombosis (VITT), as well as cases of immune thrombocytopenia (ITP). This has necessitated a better understanding of these conditions. However, as both VITT and “vaccine-associated ITP” are emerging conditions, evidence on the clinical features, epidemiology, and management is still evolving. Subsequently, with the initiation of the COVID-19 vaccine booster program, it has become increasingly important to continue to collect accurate data on post-COVID-19 vaccine complications to aid with their prompt recognition and management. In this case series, we report on the presentations and management of seven cases of post-COVID-19 vaccine-related immune-mediated complications which occurred at our center between the months of March and July 2021.

SARS CoV- 2 vaccination induces antibodies against cardiolipin

OBJECTIVE

Cases of thrombosis have been reported after administration of SARS-CoV-2 vaccines, with controversial results relating to Oxford-AstraZeneca's ChAdOx1-S. Despite such cases being rare, they still raised concerns for their involvement in coagulopathies. Anti-cardiolipin (aCL) IgG antibodies have been linked to venous and arterial thrombosis. The aim was to evaluate the concentration of aCL IgG antibodies in vaccinated and COVID-19 positive individuals using indirect ELISA and commercial sourced calibrators.

RESULTS

The concentration of aCL IgG antibodies was measured in the serum of COVID-19 positive (n = 37), ChAdOx1-S vaccinated (n = 37) and BioNTech Pfizer BNT162b2 vaccinated (n = 42) individuals. Samples from COVID-19 negative, unvaccinated individuals (n = 41) served as controls. The highest percentage of positivity was in the COVID-19 positive group (18.9%). Concerning vaccination, BNT162b2 had the highest percentage of positivity (11.9%) (p = 0.0037). Additionally, aCL concentrations were evaluated at different time points in both vaccinated groups (before, 3 weeks after and 3 months after the second dose). A significant difference in the levels of aCL IgG antibodies over time (p = 0.0391) was observed only in ChAdOx1-S individuals. Our study concluded that levels of aCL, after vaccination with either of the vaccines or following SARS-CoV-2 infection, were not clinically pathogenic for the risk of thrombosis.

SARS-CoV-2 infection in cardiovascular disease: Unmet need of stem cell models

This review aims to summarise new approaches in SARS-CoV-2-related research in cardiology. We provide a head-to-head comparison of models, such as animal research and human pluripotent stem cells, to investigate the pathomechanisms of COVID-19 and find an efficient therapy. In vivo methods were useful for studying systemic processes of the disease; however, due to differences in animal and human biology, the clinical translation of the results remains a complex task. In vitro stem cell research makes cellular events more observable and effective for finding new drugs and therapies for COVID-19, including the use of stem cells. Furthermore, multicellular 3D organoids even make it possible to observe the effects of drugs to treat SARS-CoV-2 infection in human organ models.

Endovascular treatment for vaccine-induced cerebral venous sinus thrombosis and thrombocytopenia following ChAdOx1 nCoV-19 vaccination: a report of three cases

BACKGROUND

Vaccine-induced thrombosis and thrombocytopenia (VITT) is a rare complication following ChAdOx1 nCoV-19 vaccination. Cerebral venous sinus thrombosis (CVST) is overrepresented in VITT and is often associated with multifocal venous thromboses, concomitant hemorrhage and poor outcomes. Hitherto, endovascular treatments have not been reviewed in VITT-related CVST.

METHODS

Patient records from a tertiary neurosciences center were reviewed to identify patients who had endovascular treatment for CVST in VITT.

RESULTS

Patient records from 1 January 2021 to 20 July 2021 identified three patients who underwent endovascular treatment for CVST in the context of VITT. All were female and the median age was 52 years. The location of the CVST was highly variable. Two-thirds of the patients had multifocal dural sinus thromboses (sigmoid, transverse, straight and superior sagittal) as well as internal jugular vein thromboses. Intracerebral hemorrhage occurred in all patients; subarachnoid blood was noted in two of them, and intraparenchymal hemorrhage occurred in all. There was one periprocedural parenchymal extravasation which abated on temporary cessation of anticoagulation. Outcome data revealed a 90-day modified Rankin Scale (mRS) score of 2 in all cases.

CONCLUSIONS

We demonstrate that endovascular treatment for VITT-associated CVST is feasible and can be safe in cases that deteriorate despite medical therapy. Extensive clot burden, concomitant hemorrhage, rapid clinical progression and persistent rises in intracranial pressure should initiate multidisciplinary team discussion for endovascular treatment in appropriate cases.

Acquired Hemophilia A following Pfizer-BioNTech SARS CoV-2 mRNA vaccine, successfully treated with prednisolone and rituximab

INTRODUCTION

Acquired haemophilia A (AHA) is a rare bleeding disorder, characterised by the presence of autoantibodies to clotting factor VIII (FVIII). AHA can be idiopathic or occur in the context of malignancy, autoimmune disease, drugs, or pregnancy. Recently, cases of AHA following both COVID-19 infection and vaccination have been reported.

CASE REPORT

We report the case of a 95-year-old female who was immunised with the Pfizer-BioNTech SARS CoV-2 mRNA vaccine, with doses given three weeks apart. Spontaneous bruising over her extremities appeared one week after the initial dose, with hospital admission occurring three weeks after the second. Examination revealed a large haematoma on the dorsum of the right hand with resultant bleeding and widespread ecchymoses. Investigations confirmed a diagnosis of AHA.

MANAGEMENT AND OUTCOME

Initial management included high dose prednisolone, recombinant Factor VIII and tranexamic acid. There was no significant clinical improvement after three days, so intravenous rituximab 100 mg weekly for four weeks was commenced. The activated partial thromboplastin time (aPTT) normalised after two doses and Factor VIII level reached 0.68U/ml on day + 22. The patient was successfully discharged from hospital after 37 days.

DISCUSSION

Four cases of AHA following administration of COVID mRNA vaccines (Pfizer and Moderna) have been documented. AHA should be a differential in patients presenting with bleeding following COVID-19 vaccination, in the presence of a normal platelet count. Rapid recognition, prompt initiation of immunosuppressive treatment and rigorous supportive cares are required to minimise morbidity and mortality.

Adverse Events and Safety of SARS-CoV-2 Vaccines: What's New and What's Next

Just over 1 year following rollout of the first vaccines for coronavirus disease 2019, 572 million doses have been administered in the United States. Compared with the number of vaccines administered, adverse effects such as anaphylaxis have been rare, and seemingly, the more serious the effect, the rarer the occurrence. Despite these adverse effects, there are few, if any, true contraindications to coronavirus disease 2019 vaccination and most individuals recover without further sequelae. This review provides guidance for the allergist/immunologist regarding appropriate next steps based on patient's known allergy history or adverse reaction after receipt of coronavirus disease 2019 vaccine to assist in safe global immunization.

Thrombosis after SARS-CoV2 infection or COVID-19 vaccination: will a nonpathologic anti-PF4 antibody be a solution?—A narrative review

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.

Safety of COVID-19 Vaccines: Spotlight on Neurological Complications

The COVID-19 pandemic has led to unprecedented demand on the global healthcare system. Remarkably, at the end of 2021, COVID-19 vaccines received approvals for human use in several countries worldwide. Since then, a solid base for response in the fight against the virus has been placed. COVID-19 vaccines have been shown to be safe and effective drugs. Nevertheless, all kinds of vaccines may be associated with the possible appearance of neurological complications, and COVID-19 vaccines are not free from neurological side effects. Neurological complications of COVID-19 vaccination are usually mild, short-duration, and self-limiting. However, severe and unexpected post-vaccination complications are rare but possible events. They include the Guillain-Barré syndrome, facial palsy, other neuropathies, encephalitis, meningitis, myelitis, autoimmune disorders, and cerebrovascular events. The fear of severe or fatal neurological complications fed the “vaccine hesitancy” phenomenon, posing a vital communication challenge between the scientific community and public opinion. This review aims to collect and discuss the frequency, management, and outcome of reported neurological complications of COVID-19 vaccines after eighteen months of the World Health Organization’s approval of COVID-19 vaccination, providing an overview of safety and concerns related to the most potent weapon against the SARS-CoV-2.

Autopsy findings of post-COVID-19 vaccination deaths in Tokyo Metropolis, Japan, 2021

BACKGROUND

COVID-19 vaccines have been used across Japan since 17 February 2021, and as of 17 April 2022, 1690 deaths potentially caused by vaccine-related adverse effects have been reported to the Ministry of Health, Labour and Welfare. However, the causal relationship between vaccination and death could not be fully evaluated because of a lack of sufficient information.

METHODS

Autopsy cases in which deaths occurred within seven days after COVID-19 vaccination in Tokyo Metropolis and were handled by medical examiners were selected (n = 54). Age, sex, vaccine-related information, cause of death, and possible causal relationship between vaccination and death were examined.

RESULTS

The mean age of the deceased individuals was 68.1 years, and the study sample consisted of 34 males (63.9%) and 20 females (37.0%). Thirty-seven and six individuals received Comirnaty and Spikevax, respectively (68.5% and 11.1% respectively). The manner of death included natural (n = 43), non-natural (n = 8), and undetermined (n = 3). The most frequent cause of death was ischemic heart disease (n = 16). Regarding causal relationships, 46 cases (85.2%) did not show a causal relationship to vaccination, except for myocarditis (n = 3), thrombosis-related death (n = 4), and others (n = 1).

CONCLUSION

Although many cases of deaths after COVID-19 vaccination in this study showed no definite causal relationship between the vaccination and deaths, some cases showed possible adverse events such as myocarditis. Autopsies are essential for detecting vaccine-related deaths, and the Japanese death investigation system needs to be reinforced from this viewpoint.

COVID-19 vaccine-associated ganulomatous mass mimicking a sarcoma: a case report

Several studies have previously documented the development of complications stemming from injection with one of the various COVID-19 vaccines. No study, however, has discussed the spontaneous development of a soft tissue mass shortly after a COVID-19 vaccine injection. We report on 66-year-old female with concerns of a growing shoulder mass, 2 weeks after receiving a COVID-19 vaccine booster. Initial work-up with X-ray and MRI was concerning for a soft tissue neoplasm, specifically a soft tissue sarcoma. Subsequent ultrasound guided biopsy demonstrated a benign granulomatous lesion. No further management was required as the lesion spontaneously resolved during a 3-month follow-up period.

Epidemiology and Management of Cerebral Venous Thrombosis during the COVID-19 Pandemic

Cerebral venous thrombosis (CVT) is a rare type of stroke that may cause an intracranial hypertension syndrome as well as focal neurological deficits due to venous infarcts. MRI with venography is the method of choice for diagnosis, and treatment with anticoagulants should be promptly started. CVT incidence has increased in COVID-19-infected patients due to a hypercoagulability state and endothelial inflammation. CVT following COVID-19 vaccination could be related to vaccine-induced immune thrombotic thrombocytopenia (VITT), a rare but severe complication that should be promptly identified because of its high mortality rate. Platelet count, D-dimer and PF4 antibodies should be dosed. Treatment with non-heparin anticoagulants and immunoglobulin could improve recuperation. Development of headache associated with seizures, impaired consciousness or focal signs should raise immediate suspicion of CVT. In patients who received a COVID-19 adenovirus-vector vaccine presenting thromboembolic events, VITT should be suspected and rapidly treated. Nevertheless, vaccination benefits clearly outweigh risks and should be continued.

Clinical and Genetic Characteristics of Coronaviruses with Particular Emphasis on SARS-CoV-2 Virus

The rapidly spreading Coronavirus Disease 2019 (COVID-19) pandemic has led to a global health crisis and has left a deep mark on society, culture, and the global economy. Despite considerable efforts made to contain the disease, SARS-CoV-2 still poses a threat on a global scale. The current epidemiological situation caused an urgent need to understand the basic mechanisms of the virus transmission and COVID-19 severe course. This review summarizes current knowledge on clinical courses, diagnostics, treatment, and prevention of COVID-19. Moreover, we have included the latest research results on the genetic characterization of SARS-CoV-2 and genetic determinants of susceptibility and severity to infection.

Vaccine-induced immune thrombotic thrombocytopenia after ChAdOx1 nCoV-19 vaccine in an older patient: Minireview and a case report

Rare cases of unusual thrombosis and thrombocytopenia after administration of the ChAdOx1 nCoV-19 vaccine (AstraZeneca) have been reported. The unusual symptoms are called vaccine-induced immune thrombotic thrombocytopenia (VITT). In the present study, a brief background about cases of unusual thrombosis and thrombocytopenia after administration of the ChAdOx1 nCoV-19 was provided. In addition, a description of a case of a 66-year-old woman who had received this vaccine and developed VITT was done. She presented to the hospital complaining of hematomas in the right upper limb 14 days after the ChAdOx1 nCoV-19 vaccine, without a history of trauma (Glasgow coma scale of 14) and thrombocytopenia even though signs of thrombosis were absent. Cranium computed tomography scan indicated intraparenchymal hematoma and cerebral thrombosis, besides anastomotic Labbé vein thrombosis. The woman received platelets transfusion, dexamethasone, and neuroprotection measures, but even so, on the twelfth postoperative day, she died of cerebral rebleeding. In conclusion, it is crucial to point out the immuno-hypersensitivity mechanisms associated with ChAdOx1 nCoV-19 vaccine reactions, helping to reduce their occurrences and reinforcing confidence in vaccine administration.

A case of ChAdOx1 vaccine-induced thrombocytopenia and thrombosis syndrome leading to bilateral adrenal haemorrhage and adrenal insufficiency

Summary

Vaccine-induced thrombosis and thrombocytopenia (VITT) after vaccination against SARS-CoV-2 with the adenoviral vector-based vaccines ChAdOx1 and Ad26.COV2.S has been associated with adrenal pathology, such as bilateral adrenal vein thrombosis, adrenal cortex haemorrhage and adrenal insufficiency in 6% of patients. We report the case of a 23-year-old woman who presented at 8 days after ChAdOx1 vaccination with a low platelet count of 43 × 109/L, raised d dimers >100 000 ng/mL and multiple lobar and segmental pulmonary emboli. Anti-platelet factor 4 antibodies were detected confirming definite VITT in accordance with the UK diagneostic criteria. At 16 days post-vaccine, further imaging showed bilateral adrenal haemorrhage, non-occlusive splenic vein thrombosis and right ventricular thrombosis. Her cortisol level was <25 nmol/L. She was treated with anticoagulation, plasmapheresis, immunosuppression and steroid replacement. She had high anti-spike titre and positive anti-nucleocapsid titres for SARS-CoV-2. She developed seizures secondary to posterior reversible encephalopathy, requiring intensive care. After 4 weeks in hospital, she was discharged on warfarin, hydrocortisone and fludrocortisone replacement. Short synacthen tests 3 and 9 months later showed no recovery of adrenal function, although magnetic resonance imaging of the adrenal glands showed resolving adrenal haemorrhage. Adrenal insufficiency secondary to bilateral adrenal vein thrombosis and adrenal haemorrhage should be suspected in patients with VITT and treated promptly. Adrenal vein thrombosis can occur either as the initial presentation of VITT or days to weeks after the development of thrombosis in other sites. Further studies are required to provide insight on adrenal function recovery after VITT.

Learning points

Adrenal insufficiency secondary to bilateral adrenal vein thrombosis and adrenal cortex haemorrhage should be suspected in patients with vaccine-induced thrombosis and thrombocytopenia (VITT) and treated promptly. Adrenal vein thrombosis can occur as the initial presentation of VITT or even days to weeks later after the development of thrombosis in other more classic sites (e.g. pulmonary or cerebral vasculature). Completion of vaccination schedule against SARS-CoV-2 post-VITT using an mRNA-based vaccine should be recommended to patients post-VITT as mRNA-based vaccines have not been associated with VITT but confer protection against SARS-CoV-2. There is paucity of data regarding the potential for recovery of adrenal function after bilateral adrenal haemorrhage in the context of VITT, and thus, more studies are needed to inform clinical practice. The need for disease registries for rare conditions, such as VITT, is crucial as direct cooperation and sharing of information by clinicians might enable quicker identification of disease patterns than would have been possible via established reporting tools of adverse events.

Thrombotic Complications after COVID-19 Vaccination: Diagnosis and Treatment Options

Coronavirus disease 2019 (COVID-19) vaccines were developed a few months after the emergence of the pandemic. The first cases of vaccine-induced thrombotic complications after the use of adenoviral vector vaccines ChAdOx1 nCoV-19 by AstraZeneca, and Ad26.COV2.S by Johnson & Johnson/Janssen, were announced shortly after the initiation of a global vaccination program. In these cases, the occurrence of thrombotic events at unusual sites—predominantly located in the venous vascular system—in association with concomitant thrombocytopenia were observed. Since this new entity termed vaccine-induced thrombotic thrombocytopenia (VITT) shows similar pathophysiologic mechanisms as heparin-induced thrombocytopenia (HIT), including the presence of antibodies against heparin/platelet factor 4 (PF4), standard routine treatment for thrombotic events—arterial or venous—are not appropriate and may also cause severe harm in affected patients. Thrombotic complications were also rarely documented after vaccination with mRNA vaccines, but a typical VITT phenomenon has, to date, not been established for these vaccines. The aim of this review is to give a concise and feasible overview of diagnostic and therapeutic strategies in COVID-19 vaccine-induced thrombotic complications.

Vaccine-induced immune thrombocytopaenia and thrombosis (VITT) after COVID-19 vaccination

COVID-19 represents a global health emergency, causing significant morbidity and mortality. Multiple vaccines have been distributed worldwide to control the spread of this pandemic. Several reports of thrombosis and thrombocytopaenia have been described after vaccination. These have been termed vaccine-induced immune thrombocytopaenia and thrombosis (VITT). We report a fatal case of VITT after receiving the first dose of Ad26.COV2.S vaccine. A man in his 30s developed thrombocytopaenia, massive haemoperitoneum due to spleen rupture and extensive portal and femoral vein thrombosis. The patient rapidly developed multiple organ failure and died. We attributed this condition to the vaccine due to the temporal relationship, presence of thrombosis and thrombocytopaenia, high levels of platelet factor 4 antibodies and exclusion of other diagnoses. Healthcare providers should be aware of such rare but fatal complications of COVID-19 immunisation, as early diagnosis of VITT may improve prognosis by allowing timely appropriate treatment.