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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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Warkentin TE. Heparin-induced thrombocytopenia (and autoimmune heparin-induced thrombocytopenia): an illustrious review. Res Pract Thromb Haemost 2023; 7:102245. [PMID: 38193057 PMCID: PMC10772877 DOI: 10.1016/j.rpth.2023.102245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 01/10/2024] Open
Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Kanack AJ, Athale J, Leger RR, Saadalla A, Heikal NM, Chen D, Garcia DA, Singh R, Pruthi RK, Padmanabhan A. "Autoimmune HIT" antibodies in diagnostic samples are a potential artifact and not associated with more severe outcomes. Blood Adv 2023; 7:4431-4434. [PMID: 37267446 PMCID: PMC10440464 DOI: 10.1182/bloodadvances.2023009811] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/04/2023] Open
Affiliation(s)
- Adam J. Kanack
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Janhavi Athale
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ
| | - Rachel R. Leger
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Abdul Saadalla
- Department of Pathology, University of Utah, Salt Lake City, UT
| | - Nahla M. Heikal
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Dong Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - David A. Garcia
- Department of Medicine, University of Washington, Seattle, WA
| | - Ravinder Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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Revelly E, Scala E, Rosner L, Rancati V, Gunga Z, Kirsch M, Ltaief Z, Rusca M, Bechtold X, Alberio L, Marcucci C. How to Solve the Conundrum of Heparin-Induced Thrombocytopenia during Cardiopulmonary Bypass. J Clin Med 2023; 12:jcm12030786. [PMID: 36769435 PMCID: PMC9918281 DOI: 10.3390/jcm12030786] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a major issue in cardiac surgery requiring cardiopulmonary bypass (CPB). HIT represents a severe adverse drug reaction after heparin administration. It consists of immune-mediated thrombocytopenia paradoxically leading to thrombotic events. Detection of antibodies against platelets factor 4/heparin (anti-PF4/H) and aggregation of platelets in the presence of heparin in functional in vitro tests confirm the diagnosis. Patients suffering from HIT and requiring cardiac surgery are at high risk of lethal complications and present specific challenges. Four distinct phases are described in the usual HIT timeline, and the anticoagulation strategy chosen for CPB depends on the phase in which the patient is categorized. In this sense, we developed an institutional protocol covering each phase. It consisted of the use of a non-heparin anticoagulant such as bivalirudin, or the association of unfractionated heparin (UFH) with a potent antiplatelet drug such as tirofiban or cangrelor. Temporary reduction of anti-PF4 with intravenous immunoglobulins (IvIg) has recently been described as a complementary strategy. In this article, we briefly described the pathophysiology of HIT and focused on the various strategies that can be applied to safely manage CPB in these patients.
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Affiliation(s)
- Etienne Revelly
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Correspondence:
| | - Emmanuelle Scala
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Lorenzo Rosner
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Valentina Rancati
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Ziyad Gunga
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Matthias Kirsch
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Zied Ltaief
- Department of Intensive Care Medicine, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Marco Rusca
- Department of Intensive Care Medicine, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Xavier Bechtold
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Lorenzo Alberio
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Carlo Marcucci
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
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Ultrasound Comparative Analysis of Coronary Arteries before and after Immune Blocking Therapy with Gamma Globulin in Children with Kawasaki Disease. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:2900378. [PMID: 35966739 PMCID: PMC9371854 DOI: 10.1155/2022/2900378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 05/26/2022] [Accepted: 06/29/2022] [Indexed: 11/21/2022]
Abstract
Objective To investigate the ultrasound characteristics and clinical efficacy of coronary arteries before and after immune blocking therapy with gamma globulin in children with Kawasaki disease. Methods A total of 64 children with Kawasaki disease who were treated in our hospital from January 2018 to October 2021 were selected. All the children were given immune blocking therapy with gamma globulin on the basis of conventional treatment. The disappearance time of related symptoms and signs (fever, mucosal congestion, cervical lymphadenopathy, and swelling of the hands and feet) in children were counted. The white blood cell count (WBC), platelet count (PLT), C-reactive protein (CRP), and procalcitonin (PCT) levels of the children before and after treatment were compared, and the characteristics of coronary echocardiography before and after treatment were observed for analysis and discussion, to carefully observe whether the coronary artery involvement of the children was improved. Results The inner diameter of the left and right coronary arteries significantly decreased (P < 0.05), and the levels of leukocytes, platelets, CRP, erythrocyte sedimentation rate, vascular endothelial growth factor (VEGF), and endostatin were significantly decreased compared with those before treatment, with a statistical difference (P < 0.05). Conclusion The effect of gamma globulin in the treatment of Kawasaki disease is remarkable, which can improve the blood indexes, VEGF, and endostatin levels in children, significantly reduce coronary dilatation, and reduce the incidence of coronary artery disease. Echocardiography is of high value in the examination of children with Kawasaki disease, which can accurately detect the size, location, and inner diameter of coronary artery lesions, and can effectively evaluate the treatment effect on children.
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Roberge G, Côté B, Calabrino A, Gilbert N, Gagnon N. Acute lower limb ischemia caused by vaccine-induced immune thrombotic thrombocytopenia: focus on perioperative considerations for 2 cases. Thromb J 2022; 20:38. [PMID: 35787808 PMCID: PMC9251912 DOI: 10.1186/s12959-022-00398-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 06/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND ChAdOx1 nCoV-19 (AstraZeneca) and Ad26COV2.S (Johnson & Johnson/Janssen) adenoviral vector vaccines have been associated with vaccine-induced immune thrombotic thrombocytopenia (VITT). Arterial thrombosis and acute limb ischemia have been described in a minority of patients with VITT. These patients usually need a revascularization, but they potentially are at a higher risk of complications. Optimal perioperative care of patients undergoing vascular surgery in acute VITT is unknown and important considerations in such context need to be described. CASES PRESENTATIONS We report 2 cases of VITT presenting with acute limb ischemia who needed vascular surgery and we describe the multidisciplinary team decisions for specific treatment surrounding the interventions. Both patients' platelet counts initially increased after either intravenous immune globulin (IVIG) or therapeutic plasma exchange (TPE). None received platelet transfusion. They both received argatroban as an alternative to heparin for their surgery. Despite persistent positivity of anti-platelet factor 4 (PF4) antibodies and serotonin-release assay with added PF4 (PF4-SRA) in both patients, only one received a repeated dose of IVIG before the intervention. Per- and post-operative courses were both unremarkable. CONCLUSION In spite of persistent anti-PF4 and PF4-SRA positivity in the setting of VITT, after platelet count improvement using either IVIG or TPE, vascular interventions using argatroban can show favorable courses. Use of repeated IVIG or TPE before such interventions still needs to be defined.
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Affiliation(s)
- Guillaume Roberge
- Centre d'Excellence Des Maladies Vasculaires, Centre Hospitalier Universitaire de Québec, Hôpital Saint-François d'Assise, Université Laval, Québec, Canada.
| | - Benoit Côté
- Department of General Internal Medicine, Centre Hospitalier Universitaire de Québec, Hôpital de L'Enfant-Jésus, Université Laval, Québec, Canada
| | - Anthony Calabrino
- Centre d'Excellence Des Maladies Vasculaires, Centre Hospitalier Universitaire de Québec, Hôpital Saint-François d'Assise, Université Laval, Québec, Canada
| | - Nathalie Gilbert
- Centre d'Excellence Des Maladies Vasculaires, Centre Hospitalier Universitaire de Québec, Hôpital Saint-François d'Assise, Université Laval, Québec, Canada
| | - Nathalie Gagnon
- Centre d'Excellence Des Maladies Vasculaires, Centre Hospitalier Universitaire de Québec, Hôpital Saint-François d'Assise, Université Laval, Québec, Canada
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Hsu SY, Lin CY, Cheng MH. Heparin-induced thrombocytopenia and thrombosis in primary lymphedema patients who underwent vascularized lymph node transplantations. J Surg Oncol 2022; 125:958-967. [PMID: 35107827 DOI: 10.1002/jso.26811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia and thrombosis (HITT) may result in microsurgical flap failure. This study investigated the outcomes of HITT in primary lymphedema patients who underwent vascularized lymph node transplantations (VLNT). METHODS Between 2012 and 2019, primary lymphedema patients who underwent VLNTs were retrospectively included. The 4Ts score was used to categorize patients into HITT (scores of 5-7) and non-HITT (score < 5) groups. Outcome evaluations included the re-exploration rate, success rate, circumferential differences, cellulitis episodes, and Lymphedema Specific Quality of Life Questionnaire (LYMQoL) scores. RESULTS Twenty-six and 15 patients with 31 and 16 VLNTs were included in the HITT and non-HITT groups, respectively. The HITT group had significantly greater first, second and third re-exploration rates of 38.7% (12/31), 25.7% (8/31), and 6.5% (2/31) than the non-HITT group (6.3%, 0%, and 0%, all p < 0.01), respectively. The platelet counts significantly decreased by 21.0% in the HITT group compared with the non-HITT group (14%) on postoperative Day one (p < 0.01) with a cutoff value of 17% and AUC = 0.88. CONCLUSIONS HITT may cause a high re-exploration rate of VLNTs in primary lymphedema patients. The 17% reduction in platelets on postoperative day one was an early sign for detecting HITT.
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Affiliation(s)
- Shao-Yun Hsu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Yu Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Section of Plastic Surgery, The University of Michigan, Ann Arbor, Michigan, USA
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Bavli N, Christensen B, Sarode R, Hofmann S, Ibrahim I. Therapeutic plasma exchange in severe refractory autoimmune heparin-induced thrombocytopenia with thrombosis. Br J Haematol 2021; 196:e44-e47. [PMID: 34708413 DOI: 10.1111/bjh.17917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Natalie Bavli
- Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bradley Christensen
- Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ravi Sarode
- Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Division of Transfusion Medicine and Hemostasis, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sandra Hofmann
- Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ibrahim Ibrahim
- Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Ceschia N, Scheggi V, Gori AM, Rogolino AA, Cesari F, Giusti B, Cipollini F, Marchionni N, Alterini B, Marcucci R. Diffuse prothrombotic syndrome after ChAdOx1 nCoV-19 vaccine administration: a case report. J Med Case Rep 2021; 15:496. [PMID: 34615534 PMCID: PMC8493358 DOI: 10.1186/s13256-021-03083-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vaccine-induced immune thrombotic thrombocytopenia is emerging as one of the most relevant side effects of adenoviral-based vaccines against coronavirus disease 2019. Given the novelty of this disease, the medical community is seeking new evidence and clinical experiences on the management of these patients. CASE PRESENTATION In this article, we describe the case of a 73-year-old Caucasian woman who presented with diffuse prothrombotic syndrome, both in the arterial and venous districts, following the first dose administration of ChAdOx1 CoV-19 vaccine. The main thrombotic sites included the brain, with both a cortical ischemic lesion and thromboses of the left transverse and sigmoid sinuses and the lower limbs, with deep venous thrombosis accompanied by subsegmental pulmonary thromboembolism. The deep venous thrombosis progressively evolved into acute limb ischemia, requiring surgical intervention with thromboendoarterectomy. Anticoagulation was maintained throughout the whole hospitalization period and continued in the outpatient setting using vitamin K antagonists for a recommended period of 6 months. CONCLUSIONS This case describes the management of vaccine-induced immune thrombotic thrombocytopenia in a complicated clinical scenario, including multisite arterial and venous thromboses. Given the complexity of the patient presentation, this case may implement the comprehension of the mechanisms and clinical features of this disease; it also provides a picture of the challenges related to the management, often requiring a multidisciplinary approach.
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Affiliation(s)
- Nicole Ceschia
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Valentina Scheggi
- Department of Cardiothoracovascular Medicine, AOU Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy.
| | - Anna Maria Gori
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Angela Antonietta Rogolino
- Department of Cardiothoracovascular Medicine, AOU Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Francesca Cesari
- Department of Cardiothoracovascular Medicine, AOU Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Franco Cipollini
- Department of Internal Medicine, Ospedale San Jacopo, Via Ciliegiole 97, 51100, Pistoia, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Brunetto Alterini
- Department of Cardiothoracovascular Medicine, AOU Careggi, Largo G. A. Brambilla 3, 50134, Florence, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. A. Brambilla 3, 50134, Florence, Italy
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Huang CT, Hsu SY, Wang CH, Tseng WEJ, Yang CY, Ng CJ, Warkentin TE, Cheng MH. Double high-dose immunoglobulin for ChAdOx1 nCov-19 vaccine-induced immune thrombotic thrombocytopenia. Thromb Res 2021; 206:14-17. [PMID: 34375780 PMCID: PMC8336974 DOI: 10.1016/j.thromres.2021.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/27/2021] [Accepted: 07/30/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ching-Tai Huang
- Department of Infectious Disease, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Yun Hsu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chien-Ho Wang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-En Johnny Tseng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chin-Yu Yang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chip-Jin Ng
- Department of Infectious Disease, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Section of Plastic Surgery, The University of Michigan, Ann Arbor, MI, United States of America.
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Roberge G, D'Astous J, Rodger M. Successful treatment of vaccine-induced prothrombotic immune thrombocytopenia (VIPIT): COMMENT from Roberge, et al. J Thromb Haemost 2021; 19:2091-2092. [PMID: 34327827 DOI: 10.1111/jth.15369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/01/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Guillaume Roberge
- Centre d'excellence en maladies vasculaires, Centre Hospitalier Universitaire de Québec, Université Laval, Hôpital Saint-François d'Assise, Québec City, Québec, Canada
| | - Julien D'Astous
- Department of Medicine, Centre hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Marc Rodger
- Department of Medicine, McGill University, Montréal, Québec, Canada
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Tiede A, Sachs UJ, Czwalinna A, Werwitzke S, Bikker R, Krauss JK, Donnerstag F, Weißenborn K, Höglinger G, Maasoumy B, Wedemeyer H, Ganser A. Prothrombotic immune thrombocytopenia after COVID-19 vaccination. Blood 2021; 138:350-353. [PMID: 34323939 PMCID: PMC8084604 DOI: 10.1182/blood.2021011958] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 12/15/2022] Open
Abstract
We report 5 cases of prothrombotic immune thrombocytopenia after exposure to the ChAdOx1 vaccine (AZD1222, Vaxzevria) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients presented 5 to 11 days after first vaccination. The spectrum of clinical manifestations included cerebral venous sinus thrombosis, splanchnic vein thrombosis, arterial cerebral thromboembolism, and thrombotic microangiopathy. All patients had thrombocytopenia and markedly elevated D-dimer. Autoantibodies against platelet factor 4 (PF4) were detected in all patients, although they had never been exposed to heparin. Immunoglobulin from patient sera bound to healthy donor platelets in an AZD1222-dependent manner, suppressed by heparin. Aggregation of healthy donor platelets by patient sera was demonstrated in the presence of buffer or AZD1222 and was also suppressed by heparin. Anticoagulation alone or in combination with eculizumab or intravenous immunoglobulin (IVIG) resolved the pathology in 3 patients. Two patients had thromboembolic events despite anticoagulation at a time when platelets were increasing after IVIG. In summary, an unexpected autoimmune prothrombotic disorder is described after vaccination with AZD1222. It is characterized by thrombocytopenia and anti-PF4 antibodies binding to platelets in AZD1222-dependent manner. Initial clinical experience suggests a risk of unusual and severe thromboembolic events.
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Affiliation(s)
- Andreas Tiede
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Ulrich J Sachs
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany
- Department of Thrombosis and Hemostasis, Giessen University Hospital, Giessen, Germany
| | - Andreas Czwalinna
- Amedes MVZ WagnerStibbe Center for Laboratory Medicine, Hannover, Germany; and
| | - Sonja Werwitzke
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | | | | | | | | | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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Julian K, Bucher D, Jain R. Autoimmune heparin-induced thrombocytopenia: a rare manifestation of COVID-19. BMJ Case Rep 2021; 14:14/5/e243315. [PMID: 34031097 PMCID: PMC8149303 DOI: 10.1136/bcr-2021-243315] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We describe the case of a 65-year-old male who presented to an outside hospital for shortness of breath, nausea and vomiting 8 days after testing positive for COVID-19. Initial workup revealed massive bilateral pulmonary emboli and thrombocytopenia. The patient was then admitted to our hospital, received an inferior vena cava filter and initially started on argatroban for autoimmune heparin-induced thrombocytopenia (HIT) prophylaxis. On hospital stay day 6, labs revealed a diagnosis of HIT in the setting of COVID-19. This case highlights the rare occurrence of a patient developing HIT without heparin exposure and in the setting of a novel infectious agent, COVID-19.
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Affiliation(s)
| | - Donald Bucher
- Department of Internal Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Rohit Jain
- Department of Internal Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
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Management of cerebral and splanchnic vein thrombosis associated with thrombocytopenia in subjects previously vaccinated with Vaxzevria (AstraZeneca): a position statement from the Italian Society for the Study of Haemostasis and Thrombosis (SISET). BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2021; 19:281-283. [PMID: 33871350 DOI: 10.2450/2021.0117-21] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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