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Vera IM, Kessler A, Harawa V, Ahmadu A, Keller TE, Ray ST, Taylor TE, Rogerson SJ, Mandala WL, Reyes Gil M, Seydel KB, Kim K. Prothrombotic autoantibodies targeting platelet factor 4/polyanion are associated with pediatric cerebral malaria. J Clin Invest 2024; 134:e176466. [PMID: 38652559 PMCID: PMC11142751 DOI: 10.1172/jci176466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUNDFeatures of consumptive coagulopathy and thromboinflammation are prominent in cerebral malaria (CM). We hypothesized that thrombogenic autoantibodies contribute to a procoagulant state in CM.METHODSPlasma from children with uncomplicated malaria (UM) (n = 124) and CM (n = 136) was analyzed by ELISA for a panel of 8 autoantibodies including anti-platelet factor 4/polyanion (anti-PF4/P), anti-phospholipid, anti-phosphatidylserine, anti-myeloperoxidase, anti-proteinase 3, anti-dsDNA, anti-β-2-glycoprotein I, and anti-cardiolipin. Plasma samples from individuals with nonmalarial coma (NMC) (n = 49) and healthy controls (HCs) (n = 56) were assayed for comparison. Associations with clinical and immune biomarkers were determined using univariate and logistic regression analyses.RESULTSMedian anti-PF4/P and anti-PS IgG levels were elevated in individuals with malaria infection relative to levels in HCs (P < 0.001) and patients with NMC (PF4/P: P < 0.001). Anti-PF4/P IgG levels were elevated in children with CM (median = 0.27, IQR: 0.19-0.41) compared with those with UM (median = 0.19, IQR: 0.14-0.22, P < 0.0001). Anti-PS IgG levels did not differ between patients with UM and those with CM (P = 0.39). When patients with CM were stratified by malaria retinopathy (Ret) status, the levels of anti-PF4/P IgG correlated negatively with the peripheral platelet count in patients with Ret+ CM (Spearman's rho [Rs] = 0.201, P = 0.04) and associated positively with mortality (OR = 15.2, 95% CI: 1.02-275, P = 0.048). Plasma from patients with CM induced greater platelet activation in an ex vivo assay relative to plasma from patients with UM (P = 0.02), and the observed platelet activation was associated with anti-PF4/P IgG levels (Rs= 0.293, P = 0.035).CONCLUSIONSThrombosis mediated by elevated anti-PF4/P autoantibodies may be one mechanism contributing to the clinical complications of CM.
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Affiliation(s)
- Iset M. Vera
- Division of Infectious Disease and International Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
| | - Anne Kessler
- Center for Genomics and Systems Biology, Department of Biology, New York University, New York, New York, USA
| | - Visopo Harawa
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Biomedical Department, University of Malawi College of Medicine, Blantyre, Malawi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ajisa Ahmadu
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Thomas E. Keller
- Division of Infectious Disease and International Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
| | - Stephen T.J. Ray
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Terrie E. Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, Michigan State University, East Lansing, Michigan, USA
| | - Stephen J. Rogerson
- Department of Medicine (RMH), and
- Department of Infectious Diseases, Doherty Institute, The University of Melbourne, Melbourne, Australia
| | - Wilson L. Mandala
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Biomedical Department, University of Malawi College of Medicine, Blantyre, Malawi
- Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi
| | - Morayma Reyes Gil
- Department of Pathology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Karl B. Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, Michigan State University, East Lansing, Michigan, USA
| | - Kami Kim
- Division of Infectious Disease and International Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
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van der Neut Kolfschoten M, Inganäs H, Perez-Peinado C, Calado da Silva Freire J, Melchers JM, van Dijk N, Przeradzka M, Kourkouta E, van Manen D, Vellinga J, Custers J, Bos R. Biophysical studies do not reveal direct interactions between human PF4 and Ad26.COV2.S vaccine. J Thromb Haemost 2024; 22:1046-1055. [PMID: 38159648 DOI: 10.1016/j.jtha.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/12/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND COVID-19 vaccines have been widely used to control the SARS-CoV-2 pandemic. In individuals receiving replication-incompetent, adenovirus vector-based COVID-19 vaccines (eg, ChAdOx1 nCoV-19 [AstraZeneca] or Ad26.COV2.S [Johnson & Johnson/Janssen] vaccines), a very rare but serious adverse reaction has been reported and described as vaccine-induced immune thrombotic thrombocytopenia (VITT). The exact mechanism of VITT following Ad26.COV2.S vaccination is under investigation. Antibodies directed against human platelet factor 4 (PF4) are considered critical in the pathogenesis of VITT, suggesting similarities with heparin-induced thrombocytopenia. It has been postulated that components of these vaccines mimic the role of heparin by binding to PF4, triggering production of these anti-PF4 antibodies. OBJECTIVES This study aimed to investigate the potential interaction between human PF4 and Ad26.COV2.S vaccine using several biophysical techniques. METHODS Direct interaction of PF4 with Ad26.COV2.S vaccine was investigated using dynamic light scattering, biolayer interferometry, and surface plasmon resonance. For both biosensing methods, the Ad26.COV2.S vaccine was immobilized to the sensor surface and PF4 was used as analyte. RESULTS No direct interactions between PF4 and Ad26.COV2.S vaccine could be detected using dynamic light scattering and biolayer interferometry. Surface plasmon resonance technology was shown to be unsuitable to investigate these types of interactions. CONCLUSION Our findings make it very unlikely that direct binding of PF4 to Ad26.COV2.S vaccine or components thereof is driving the onset of VITT, although the occurrence of such interactions after immunization (potentially facilitated by unknown plasma or cellular factors) cannot be excluded. Further research is warranted to improve the understanding of the full mechanism of this adverse reaction.
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Affiliation(s)
| | - Hanna Inganäs
- Janssen Vaccines & Prevention B.V., Leiden, South Holland, The Netherlands
| | | | | | - Jelle M Melchers
- Janssen Vaccines & Prevention B.V., Leiden, South Holland, The Netherlands
| | - Nelie van Dijk
- Janssen Vaccines & Prevention B.V., Leiden, South Holland, The Netherlands
| | | | - Eleni Kourkouta
- Janssen Vaccines & Prevention B.V., Leiden, South Holland, The Netherlands
| | - Danielle van Manen
- Janssen Vaccines & Prevention B.V., Leiden, South Holland, The Netherlands
| | - Jort Vellinga
- Janssen Vaccines & Prevention B.V., Leiden, South Holland, The Netherlands
| | - Jerome Custers
- Janssen Vaccines & Prevention B.V., Leiden, South Holland, The Netherlands
| | - Rinke Bos
- Janssen Vaccines & Prevention B.V., Leiden, South Holland, The Netherlands.
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Ngo ATP, Bochenek V, Gollomp K. The immunology of PF4 polyanion interactions. Curr Opin Hematol 2023; 30:219-229. [PMID: 37603711 DOI: 10.1097/moh.0000000000000782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
PURPOSE OF REVIEW Platelet factor 4 (PF4, CXCL4), the most abundant α-granule platelet-specific chemokine, forms tetramers with an equatorial ring of high positive charge that bind to a wide range of polyanions, after which it changes conformation to expose antigenic epitopes. Antibodies directed against PF4 not only help to clear infection but can also lead to the development of thrombotic disorders such as heparin-induced thrombocytopenia (HIT) and vaccine-induced thrombocytopenia and thrombosis (VITT). This review will outline the different mechanisms through which PF4 engagement with polyanions combats infection but also contributes to the pathogenesis of inflammatory and thrombotic disease states. RECENT FINDINGS Recent work has shown that PF4 binding to microbial polyanions may improve outcomes in infection by enhancing leukocyte-bacterial binding, tethering pathogens to neutrophil extracellular traps (NETs), decreasing the thrombotic potential of NET DNA, and modulating viral infectivity. However, PF4 binding to nucleic acids may enhance their recognition by innate immune receptors, leading to autoinflammation. Lastly, while HIT is induced by platelet activating antibodies that bind to PF4/polyanion complexes, VITT, which occurs in a small subset of patients treated with COVID-19 adenovirus vector vaccines, is characterized by prothrombotic antibodies that bind to PF4 alone. SUMMARY Investigating the complex interplay of PF4 and polyanions may provide insights relevant to the treatment of infectious disease while also improving our understanding of the pathogenesis of thrombotic disorders driven by anti-PF4/polyanion and anti-PF4 antibodies.
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Affiliation(s)
- Anh T P Ngo
- Division of Hematology, Children's Hospital of Philadelphia
| | | | - Kandace Gollomp
- Division of Hematology, Children's Hospital of Philadelphia
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Dabbiru VAS, Müller L, Schönborn L, Greinacher A. Vaccine-Induced Immune Thrombocytopenia and Thrombosis (VITT)-Insights from Clinical Cases, In Vitro Studies and Murine Models. J Clin Med 2023; 12:6126. [PMID: 37834770 PMCID: PMC10573542 DOI: 10.3390/jcm12196126] [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: 08/10/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
An effective worldwide vaccination campaign started and is still being carried out in the face of the coronavirus disease 2019 (COVID-19) pandemic. While vaccines are great tools to confront the pandemic, predominantly adenoviral vector-based vaccines can cause a rare severe adverse effect, termed vaccine-induced immune thrombocytopenia and thrombosis (VITT), in about 1 in 100,000 vaccinated individuals. VITT is diagnosed 5-30 days post-vaccination and clinically characterized by thrombocytopenia, strongly elevated D-dimer levels, platelet-activating anti-platelet factor 4 (PF4) antibodies and thrombosis, especially at atypical sites such as the cerebral venous sinus and/or splanchnic veins. There are striking similarities between heparin-induced thrombocytopenia (HIT) and VITT. Both are caused by anti-PF4 antibodies, causing platelet and leukocyte activation which results in massive thrombo-inflammation. However, it is still to be determined why PF4 becomes immunogenic in VITT and which constituent of the vaccine triggers the immune response. As VITT-like syndromes are increasingly reported in patients shortly after viral infections, direct virus-PF4 interactions might be most relevant. Here we summarize the current information and hypotheses on the pathogenesis of VITT and address in vivo models, especially murine models for further studies on VITT.
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Affiliation(s)
| | | | | | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, 17489 Greifswald, Germany; (V.A.S.D.); (L.M.); (L.S.)
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Kunze R, Fischer S, Marti HH, Preissner KT. Brain alarm by self-extracellular nucleic acids: from neuroinflammation to neurodegeneration. J Biomed Sci 2023; 30:64. [PMID: 37550658 PMCID: PMC10405513 DOI: 10.1186/s12929-023-00954-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/22/2023] [Indexed: 08/09/2023] Open
Abstract
Neurological disorders such as stroke, multiple sclerosis, as well as the neurodegenerative diseases Parkinson's or Alzheimer's disease are accompanied or even powered by danger associated molecular patterns (DAMPs), defined as endogenous molecules released from stressed or damaged tissue. Besides protein-related DAMPs or "alarmins", numerous nucleic acid DAMPs exist in body fluids, such as cell-free nuclear and mitochondrial DNA as well as different species of extracellular RNA, collectively termed as self-extracellular nucleic acids (SENAs). Among these, microRNA, long non-coding RNAs, circular RNAs and extracellular ribosomal RNA constitute the majority of RNA-based DAMPs. Upon tissue injury, necrosis or apoptosis, such SENAs are released from neuronal, immune and other cells predominantly in association with extracellular vesicles and may be translocated to target cells where they can induce intracellular regulatory pathways in gene transcription and translation. The majority of SENA-induced signaling reactions in the brain appear to be related to neuroinflammatory processes, often causally associated with the onset or progression of the respective disease. In this review, the impact of the diverse types of SENAs on neuroinflammatory and neurodegenerative diseases will be discussed. Based on the accumulating knowledge in this field, several specific antagonistic approaches are presented that could serve as therapeutic interventions to lower the pathological outcome of the indicated brain disorders.
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Affiliation(s)
- Reiner Kunze
- Institute of Physiology and Pathophysiology, Department of Cardiovascular Physiology, Ruprecht-Karls-University, Im Neuenheimer Feld 326, 69120 Heidelberg, Germany
| | - Silvia Fischer
- Department of Biochemistry, Medical School, Justus-Liebig-University, Giessen, Germany
| | - Hugo H. Marti
- Institute of Physiology and Pathophysiology, Department of Cardiovascular Physiology, Ruprecht-Karls-University, Im Neuenheimer Feld 326, 69120 Heidelberg, Germany
| | - Klaus T. Preissner
- Department of Biochemistry, Medical School, Justus-Liebig-University, Giessen, Germany
- Kerckhoff-Heart-Research-Institute, Department of Cardiology, Medical School, Justus-Liebig-University, Giessen, Germany
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Singh RB, Parmar UPS, Gupta R, Garcia AJV, Cho W, Singh KP, Agarwal A. Retinal vascular occlusion following SARS-CoV-2 vaccination: A VAERS database analysis. OPHTHALMOLOGY SCIENCE 2023; 4:100354. [PMID: 37362418 PMCID: PMC10281033 DOI: 10.1016/j.xops.2023.100354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023]
Abstract
Purpose To evaluate the cases of retinal vessel occlusion following COVID-19 vaccination and evaluate the onset interval and clinical presentations in patients diagnosed with vaccine associated retinal artery occlusion (RAO) and retinal vein occlusion (RVO). Design Retrospective study of the cases reported to the Centers for Disease Control and Prevention (CDC) Vaccine Adverse Events Reporting System (VAERS) between December 11, 2020 and July 1, 2022. Participants Patients diagnosed with retinal vessel occlusion following vaccination with BNT162b2, mRNA-1273, and Ad26.COV2.S globally. Methods We performed a descriptive analysis of the patient demographics and clinical presentation in patients with retinal vessel occlusion. The correlation between the vaccines and continuous and categorical variables were assessed. We performed the post-hoc analysis to evaluated the association between RAO and RVO onset post-vaccination, and vaccine and dosage. Finally, a 30-day reverse analysis for RAO and RVO onset following administration of vaccine. A major limitation in the methods of this study is the lack of control group for assessing the risk of retinal vessel occlusive disease in patients who received the vaccine compared to the patients who were unvaccinated. Main Outcome Measures The crude reporting rate of retinal vessel occlusion following SARS-CoV-2 vaccine. The ocular and systemic presentations, onset duration and short term risk of RAO and RVO following vaccination. Results During the study period, 1351 retinal vessel occlusion cases were reported globally. The crude reporting rates of retinal vessel occlusion for BNT162b2, mRNA-1273, and Ad26.COV2.S were 0.36, 0.41, and 0.69, respectively. The majority of the retinal vessel occlusion cases were reported following BNT162b2 (n=606, 74.17%). The mean age of patients with RVO and RAO was 58.54 ± 16.06 years and 64.63 ± 16.16 years, respectively. In the cohort, 817 and 433 patients were diagnosed with RVO and RAO, respectively. Most cases of RVO (41.12%) and RAO (48.27%) were reported within the first week post-vaccination. We observed that the mean onset interval for RVO was significantly longer in patients who received Ad26.Cov2.S (54.07 ± 88.98 days) compared to BNT162b2 (18.07 ± 28.66 days) and mRNA-1273 (22.85 ± 38.13 days) vaccines (p<0.0001). This was further confirmed by post-hoc analysis, which revealed a significantly longer onset duration for the Ad26.Cov2.S compared to BNT162b2 and mRNA 1273 vaccines (p<0.0001). The reverse Kaplan Meier 30-day risk analysis showed a significant a higher risk of RVO onset following BNT162b2 compared to other vaccines(p<0.0001). Conclusions The low crude reporting rate highlights a low safety concern for retinal vessel occlusion following SARS-CoV-2 vaccination. This study provides insights into possible temporal association between reported retinal vessel occlusion events with SARS-CoV-2 vaccines, however further insights are needed to understand the underlying immunopathological mechanisms that promote thrombosis of retinal vasculature on vaccine administration.
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Affiliation(s)
- Rohan Bir Singh
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
- Department of Ophthalmology, Leiden University Medical Center, Leiden, the Netherlands
- Discipline of Ophthalmology and Visual Sciences, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Australia
| | | | - Rudraksh Gupta
- Discipline of Ophthalmology and Visual Sciences, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Australia
| | - Antonio Jacobo Vega Garcia
- Discipline of Ophthalmology and Visual Sciences, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Australia
| | - Wonkyung Cho
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | | | - Aniruddha Agarwal
- Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
- Department of Ophthalmology, Maastricht University Medical Center+, Maastricht, the Netherlands
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Valenzuela A, Ayuso M, Buyssens L, Bars C, Van Ginneken C, Tessier Y, Van Cruchten S. Platelet Activation by Antisense Oligonucleotides (ASOs) in the Göttingen Minipig, including an Evaluation of Glycoprotein VI (GPVI) and Platelet Factor 4 (PF4) Ontogeny. Pharmaceutics 2023; 15:pharmaceutics15041112. [PMID: 37111598 PMCID: PMC10143489 DOI: 10.3390/pharmaceutics15041112] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/06/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Antisense oligonucleotide (ASO) is a therapeutic modality that enables selective modulation of undruggable protein targets. However, dose- and sequence-dependent platelet count reductions have been reported in nonclinical studies and clinical trials. The adult Göttingen minipig is an acknowledged nonclinical model for ASO safety testing, and the juvenile Göttingen minipig has been recently proposed for the safety testing of pediatric medicines. This study assessed the effects of various ASO sequences and modifications on Göttingen minipig platelets using in vitro platelet activation and aggregometry assays. The underlying mechanism was investigated further to characterize this animal model for ASO safety testing. In addition, the protein abundance of glycoprotein VI (GPVI) and platelet factor 4 (PF4) was investigated in the adult and juvenile minipigs. Our data on direct platelet activation and aggregation by ASOs in adult minipigs are remarkably comparable to human data. Additionally, PS ASOs bind to platelet collagen receptor GPVI and directly activate minipig platelets in vitro, mirroring the findings in human blood samples. This further corroborates the use of the Göttingen minipig for ASO safety testing. Moreover, the differential abundance of GPVI and PF4 in minipigs provides insight into the influence of ontogeny in potential ASO-induced thrombocytopenia in pediatric patients.
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Functions and cellular signaling by ribosomal extracellular RNA (rexRNA): Facts and hypotheses on a non-typical DAMP. BIOCHIMICA ET BIOPHYSICA ACTA. MOLECULAR CELL RESEARCH 2023; 1870:119408. [PMID: 36503009 DOI: 10.1016/j.bbamcr.2022.119408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/07/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022]
Abstract
Upon microbial infections with the subsequent host response of innate immunity, a variety of fragmented RNA- and DNA-based "Pathogen-associated molecular patterns" (PAMPs) are recognized mainly by endosomal or cytoplasmic host cell "Pattern recognition receptors" (PRRs), particularly "Toll-like receptors" (TLRs). Concomitantly, various self-extracellular RNA species (exRNAs) are present in extracellular body fluids where they contribute to diverse physiological and homeostatic processes. In principle, such exRNAs, including the most abundant one, ribosomal exRNA (rexRNA), are designated as "Danger-associated molecular patterns" (DAMPs) and are prevented by e.g. natural modifications from uncontrolled signaling via TLRs to avoid hyper-inflammatory responses or autoimmunity. Upon cellular stress or tissue damage/necrosis, the levels and composition of released self-exRNA species, either in free form, in complex with proteins or in association with extracellular vesicles (EVs), can change considerably. Among the self-exRNAs, rexRNA is considered as a non-typical DAMP, since it may induce inflammatory responses by cell membrane receptors, both in the absence or presence of PAMPs. Yet, its mode of receptor activation to mount inflammatory responses remains obscure. RexRNA also serves as a universal damaging factor in cardiovascular and other diseases independent of PRRs. In general, RNase1 provides a profound antagonist in these pathologies and in rexRNA-mediated inflammatory cell responses. Based on the extrapolation of the here described aspects of rexRNA-biology, further activities of this molecular entity are hypothesized that may stimulate additional research in this area.
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Salih F, Schönborn L, Endres M, Greinacher A. Immunvermittelte Sinus- und Hirnvenenthrombosen: VITT und
prä-VITT als Modellerkrankung. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1936-3123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ZusammenfassungIn diesem Übersichtsartikel beschreiben wir die klinischen und
paraklinischen Charakteristika der Vakzin-induzierten immunthrombotischen
Thrombozytopenie (VITT) und fassen den gegenwärtigen Kenntnisstand zur
Pathogenese zusammen. Bei der VITT bilden sich 5–20 Tage nach einer
Impfung mit einem Adenovirus-vektorbasiertem SARS-CoV-2-Vakzin (AstraZeneca oder
Johnson & Johnson) lebensbedrohliche Thrombosen aus, vor allem in den
zerebralen Sinus und Hirnvenen. Laborchemisch zeigt sich eine typische
Thrombozytopenie mit erhöhten D-Dimeren. Der Pathogenese liegen
immunologische Prozesse zugrunde, die Ähnlichkeiten mit der
Heparin-induzierten Thrombozytopenie aufweisen: so geht die VITT mit
hochtitrigem Immunoglobulin G gegen das thrombozytäre Protein
Plättchenfaktor 4 (PF4) einher. Durch die Interaktion mit dem Impfstoff
wird PF4 so verändert, dass es von Antikörper-produzierenden
Zellen des Immunsystems erkannt wird. Die so produzierten
Anti-PF4-Antikörper führen über thrombozytäre
FcγIIa-Rezeptoren zu einer Plättchenaktivierung. Der Nachweis
plättchenaktivierender Anti-PF4-Antikörper bestätigt die
Diagnose einer VITT. Antikoagulanzien, die die Bildung von Thrombin oder
Thrombin selbst blockieren und hochdosiertes i. v.-Immunglobulin G, das
die Fcγ-Rezeptor-vermittelte Zellaktivierung inhibiert, stellen die
wirksame und kausale Behandlung der VITT dar. Bei Patienten mit katastrophalem
Verlauf kann ein Plasmaaustausch versucht werden. Bei einigen Patienten ist ein
prä-VITT Syndrom als Prodromalstadium zu beoachten, das sich
typischerweise mit Kopfschmerzen manifestieren kann und dessen frühe
Behandlung hilft, thrombotische Komplikationen zu vermeiden. Die spezifische
Dynamik der VITT-assozierten Immunreaktion entspricht einer transienten,
sekundären Immunantwort. Aktuelle Studien gehen der Frage nach, wie PF4
an unterschiedliche adenovirale Proteine bindet und beleuchten die Rolle von
anderen Impfstoff-Bestandteilen als potentielle Liganden für die
PF4-Bindung. Einige dieser Faktoren sind auch an der Etablierung eines
proinflammatorischen Milieus („danger signal“) beteiligt, das
unmittelbar nach der Impfung die 1. Phase der VITT-Pathogenese triggert. Sobald
in der 2. Phase der VITT-Pathogenese hohe Titer von Anti-PF4-Antikörper
gebildet sind, aktivieren diese neben Thrombozyten auch Granulozyten. In einem
als NETose (von „neutrophil extracellular traps“) bezeichneten
Prozess setzen aktivierte Granulozyten dabei DNA frei, mit der PF4 weitere
Komplexe bildet, an die Anti-PF4-Antikörper binden. Dies
verstärkt die Fcγ-Rezeptor-vermittelte Zellaktivierung weiter
mit der Folge einer ausgeprägten Thrombin-Bildung. Zum Ende des Artikels
geben wir einen Ausblick, welchen Einfluss die bisherigen Erkenntnisse zur VITT
auf weitere globale Impfkampagnen gegen SARS-CoV-2 haben und beleuchten, wie
Anti-PF4-Antikörper jenseits von VITT und HIT auch eine Rolle bei
seltenen Erkrankungen spielen, die mit rezidivierenden venösen und
arteriellen Thrombosen einhergehen.
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Affiliation(s)
- Farid Salih
- Klinik für Neurologie mit Experimenteller Neurologie,
Charité Universitätsmedizin Berlin, Berlin,
Germany
| | - Linda Schönborn
- Institut für Transfusionsmedizin, Universitätsmedizin
Greifswald, Greifswald, Germany
| | - Matthias Endres
- Klinik für Neurologie mit Experimenteller Neurologie,
Charité Universitätsmedizin Berlin, Berlin,
Germany
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin
Greifswald, Greifswald, Germany
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Marietta M, Coluccio V, Luppi M. Potential mechanisms of vaccine-induced thrombosis. Eur J Intern Med 2022; 105:1-7. [PMID: 35953336 PMCID: PMC9359676 DOI: 10.1016/j.ejim.2022.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 08/04/2022] [Indexed: 12/24/2022]
Abstract
Vaccine-induced immune thrombocytopenia and thrombosis (VITT) is a rare syndrome characterized by high-titer anti-platelet factor 4 (PF4) antibodies, thrombocytopenia and arterial and venous thrombosis in unusual sites, as cerebral venous sinuses and splanchnic veins. VITT has been described to occur almost exclusively after administration of ChAdOx1 nCoV-19 and Ad26.COV2.S adenovirus vector- based COVID-19 vaccines. Clinical and laboratory features of VITT resemble those of heparin-induced thrombocytopenia (HIT). It has been hypothesized that negatively charged polyadenylated hexone proteins of the AdV vectors could act as heparin to induce the conformational changes of PF4 molecule that lead to the formation of anti-PF4/polyanion antibodies. The anti-PF4 immune response in VITT is fostered by the presence of a proinflammatory milieu, elicited by some impurities found in ChAdOx1 nCoV-19 vaccine, as well as by soluble spike protein resulting from alternative splice events. Anti-PF4 antibodies bind PF4, forming immune complexes which activate platelets, monocytes and granulocytes, resulting in the VITT's immunothrombosis. The reason why only a tiny minority of patents receiving AdV-based COVID-19 vaccines develop VITT is still unknown. It has been hypothesized that individual intrinsic factors, either acquired (i.e., pre-priming of B cells to produce anti-PF4 antibodies by previous contacts with bacteria or viruses) or inherited (i.e., differences in platelet T-cell ubiquitin ligand-2 [TULA-2] expression) can predispose a few subjects to develop VITT. A better knowledge of the mechanistic basis of VITT is essential to improve the safety and the effectiveness of future vaccines and gene therapies using adenovirus vectors.
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Affiliation(s)
- Marco Marietta
- Hematology Unit, Azienda Ospedaliero- Universitaria, Modena, Italy.
| | - Valeria Coluccio
- Hematology Unit, Azienda Ospedaliero- Universitaria, Modena, Italy
| | - Mario Luppi
- Hematology Unit, Azienda Ospedaliero- Universitaria, Modena, Italy; Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
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11
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Greinacher A. COVID vaccine-induced immune thrombotic thrombocytopenia: Rare but relevant. Eur J Intern Med 2022; 105:20-22. [PMID: 36127219 DOI: 10.1016/j.ejim.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/13/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Andreas Greinacher
- Universitätsmedizin Greifswald, Sauerbruchstraße, Greifswald 17475, Germany.
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12
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Fujita M, Maeda T, Miyata S, Mizugaki A, Hayakawa M, Miyagawa N, Ushio N, Shiraishi A, Ogura T, Irino S, Sekine K, Fujinami Y, Kiridume K, Hifumi T, Kushimoto S. Association of trauma severity with antibody seroconversion in heparin-induced thrombocytopenia: A multicenter, prospective, observational study. J Trauma Acute Care Surg 2022; 93:402-408. [PMID: 35271548 PMCID: PMC9398508 DOI: 10.1097/ta.0000000000003603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/12/2022] [Accepted: 02/27/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Heparin administration can induce the production of anti-platelet factor 4 (PF4)/heparin antibodies with platelet-activating properties, causing heparin-induced thrombocytopenia (HIT). Previous studies have suggested that trauma severity influences HIT immune responses, but their relationship has not been fully explained. This study aimed to clarify this association by multicenter prospective observational study. METHODS Trauma patients who met the criteria of age 18 years or older and Injury Severity Scores (ISSs) of ≥9 from March 2018 to February 2019 were included. Patients who did not receive any heparin and those who received it as flushes or for treatment were also included. Patients were divided into three groups based on trauma severity (to mild [ISS 9-15], moderate [ISS 16-24], and severe injury groups [ISS ≥25]) and were compared by the seroconversion time and rate, as well as the disappearance rate of antibodies on day 30. RESULTS A total of 184 patients were included: 55, 62, and 67 patients were classified into the mild, moderate, and severe injury groups, respectively. Overall, the seroconversion rates of anti-PF4/heparin immunoglobulin G (IgG) and HIT antibodies by washed platelet activation assay were 26.6% and 16.3%, respectively. There was a significant difference in the seroconversion rates of anti-PF4/heparin IgG ( p = 0.016) and HIT antibodies ( p = 0.046) among the groups. Seroconversion rates in both assays increased with increasing trauma severity. The time required to achieve seroconversion was similar (between 5 and 10 days of trauma onset) regardless of heparin administration. Anti-PF4/heparin IgG and HIT antibodies were no longer detected on day 30 in 28.6% and 60.9% of seroconverted patients, respectively. CONCLUSION Development of HIT antibodies was observed commonly in severely injured trauma patients. Heparin-induced thrombocytopenia antibody development may be related to trauma severity, with a high disappearance frequency on day 30. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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13
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Nofi CP, Wang P, Aziz M. Chromatin-Associated Molecular Patterns (CAMPs) in sepsis. Cell Death Dis 2022; 13:700. [PMID: 35961978 PMCID: PMC9372964 DOI: 10.1038/s41419-022-05155-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 01/21/2023]
Abstract
Several molecular patterns have been identified that recognize pattern recognition receptors. Pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs) are commonly used terminologies to classify molecules originating from pathogen and endogenous molecules, respectively, to heighten the immune response in sepsis. Herein, we focus on a subgroup of endogenous molecules that may be detected as foreign and similarly trigger immune signaling pathways. These chromatin-associated molecules, i.e., chromatin containing nuclear DNA and histones, extracellular RNA, mitochondrial DNA, telomeric repeat-containing RNA, DNA- or RNA-binding proteins, and extracellular traps, may be newly classified as chromatin-associated molecular patterns (CAMPs). Herein, we review the release of CAMPs from cells, their mechanism of action and downstream immune signaling pathways, and targeted therapeutic approaches to mitigate inflammation and tissue injury in inflammation and sepsis.
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Affiliation(s)
- Colleen P. Nofi
- grid.250903.d0000 0000 9566 0634Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, Manhasset, NY USA ,Elmezi Graduate School of Molecular Medicine, Manhasset, NY USA ,grid.512756.20000 0004 0370 4759Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY USA
| | - Ping Wang
- grid.250903.d0000 0000 9566 0634Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, Manhasset, NY USA ,Elmezi Graduate School of Molecular Medicine, Manhasset, NY USA ,grid.512756.20000 0004 0370 4759Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY USA ,grid.512756.20000 0004 0370 4759Department of Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY USA
| | - Monowar Aziz
- grid.250903.d0000 0000 9566 0634Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, Manhasset, NY USA ,Elmezi Graduate School of Molecular Medicine, Manhasset, NY USA ,grid.512756.20000 0004 0370 4759Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY USA ,grid.512756.20000 0004 0370 4759Department of Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY USA
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14
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Hsieh MH, Yamaguchi Y. Immune Response in Regard to Hypersensitivity Reactions after COVID-19 Vaccination. Biomedicines 2022; 10:biomedicines10071641. [PMID: 35884946 PMCID: PMC9312871 DOI: 10.3390/biomedicines10071641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/02/2022] [Accepted: 07/05/2022] [Indexed: 11/16/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), is a member of the genus Betacoronavirus. This virus was first detected in December 2019, and the situation quickly escalated to cause a global pandemic within a few months. COVID-19 had caused more than 5.5 million deaths as of January 2022. Hence, the urgency of effective vaccination contributed to the fastest rate of vaccine development seen to date (i.e., within 1.5 years). Despite reports of good vaccine efficacy without severe systemic reactions at the clinical trial stage, hypersensitivity reactions have been reported following worldwide vaccination campaigns. We provide a brief review regarding the structure of SARS-CoV-2. We also review the most acceptable types of vaccines in terms of safety profiles, namely the BNT162b2, mRNA-1273, and AZD1222 vaccines. This review aims to facilitate an understanding of the possible immune mechanisms regarding COVID-19-vaccination-related hypersensitivity reactions, such as thrombosis and thrombocytopenia, cutaneous adverse reactions, myocarditis, and perimyocarditis.
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15
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Zhang J, Zhang D, Zhao J. CFNAs of RBCs affect the release of inflammatory factors through the expression of CaMKIV in macrophages. Transfus Apher Sci 2022; 61:103494. [PMID: 35773126 DOI: 10.1016/j.transci.2022.103494] [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: 04/07/2022] [Revised: 06/11/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Blood transfusions reportedly modulate the recipient's immune system. Transfusion-related immunomodulation has been suggested as a mechanism of some adverse clinical outcomes. Extracellular nucleic acids circulate in plasma and activate relevant immune responses, but little is known about their mechanism of action in transfusion-related immunomodulation (TRIM). The aim of this study was to investigate the effects of cell-free nucleic acids (CFNAs) produced by red blood cells (RBCs) on innate immunity, especially peripheral blood mononuclear cells (PBMCs) and macrophages, and to investigate the mechanism of action. METHODS Differentially expressed genes (DEGs) between PBMCs exposed to RBC-produced CFNA and normal PBMCs were analyzed by gene expression data combined with bioinformatics. KEGG and GO enrichment analyses were performed for the DEGs, and in vitro experiments were performed for the effects of key genes on the release of inflammatory factors from macrophages. RESULTS Analysis of microarray data showed that exposure of monocytes to RBC-produced CFNAs increased the expression of genes involved in the innate immune response, including chemokines, chemokine receptors, and innate response receptors, and that calcium channel activity was highly regulated, with a key gene being CaMKIV. CaMKIV played a critical role in LPS-induced inflammatory factor release from macrophages, which was exacerbated by overexpression of the CaMKIV gene. CONCLUSION RBCs regulate the release of inflammatory factors during blood transfusion by releasing CFNAs and affecting expression of the CaMKIV gene in PBMCs or macrophages, which is a potential regulatory mechanism of blood transfusion-related immune regulation and related adverse reactions.
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Affiliation(s)
- Jingrui Zhang
- Department of Transfusion Medicine, General Hospital of Northern Theater Command, Shenyang 110000, China.
| | - Dan Zhang
- Department of Transfusion Medicine, General Hospital of Northern Theater Command, Shenyang 110000, China
| | - Jing Zhao
- Department of Transfusion Medicine, General Hospital of Northern Theater Command, Shenyang 110000, China
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16
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Mingot-Castellano ME, Butta N, Canaro M, del Carmen Gómez del Castillo Solano M, Sánchez-González B, Jiménez-Bárcenas R, Pascual-Izquierdo C, Caballero-Navarro G, Entrena Ureña L, José González-López T. COVID-19 Vaccines and Autoimmune Hematologic Disorders. Vaccines (Basel) 2022; 10:vaccines10060961. [PMID: 35746569 PMCID: PMC9231220 DOI: 10.3390/vaccines10060961] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/12/2022] [Accepted: 06/15/2022] [Indexed: 02/06/2023] Open
Abstract
Worldwide vaccination against SARS-CoV-2 has allowed the detection of hematologic autoimmune complications. Adverse events (AEs) of this nature had been previously observed in association with other vaccines. The underlying mechanisms are not totally understood, although mimicry between viral and self-antigens plays a relevant role. It is important to remark that, although the incidence of these AEs is extremely low, their evolution may lead to life-threatening scenarios if treatment is not readily initiated. Hematologic autoimmune AEs have been associated with both mRNA and adenoviral vector-based SARS-CoV-2 vaccines. The main reported entities are secondary immune thrombocytopenia, immune thrombotic thrombocytopenic purpura, autoimmune hemolytic anemia, Evans syndrome, and a newly described disorder, so-called vaccine-induced immune thrombotic thrombocytopenia (VITT). The hallmark of VITT is the presence of anti-platelet factor 4 autoantibodies able to trigger platelet activation. Patients with VITT present with thrombocytopenia and may develop thrombosis in unusual locations such as cerebral beds. The management of hematologic autoimmune AEs does not differ significantly from that of these disorders in a non-vaccine context, thus addressing autoantibody production and bleeding/thromboembolic risk. This means that clinicians must be aware of their distinctive signs in order to diagnose them and initiate treatment as soon as possible.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS/CSIC), 41013 Sevilla, Spain
- Correspondence:
| | - Nora Butta
- Hospital Universitario La Paz-IdiPAZ, 28046 Madrid, Spain;
| | - Mariana Canaro
- Hematology Department, Hospital Universitario Son Espases, 07210 Palma, Spain;
| | | | | | | | - Cristina Pascual-Izquierdo
- Department of Hematology, Gregorio Marañón General University Hospital (HGUGM) Madrid, Instituto de Investigación Gregorio Marañón, 28009 Madrid, Spain;
| | | | - Laura Entrena Ureña
- Hematology Department, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
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17
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de Buhr N, Baumann T, Werlein C, Fingerhut L, Imker R, Meurer M, Götz F, Bronzlik P, Kühnel MP, Jonigk DD, Ernst J, Leotescu A, Gabriel MM, Worthmann H, Lichtinghagen R, Tiede A, von Köckritz-Blickwede M, Falk CS, Weissenborn K, Schuppner R, Grosse GM. Insights Into Immunothrombotic Mechanisms in Acute Stroke due to Vaccine-Induced Immune Thrombotic Thrombocytopenia. Front Immunol 2022; 13:879157. [PMID: 35619694 PMCID: PMC9128407 DOI: 10.3389/fimmu.2022.879157] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/11/2022] [Indexed: 12/29/2022] Open
Abstract
During the COVID-19 pandemic, vaccination is the most important countermeasure. Pharmacovigilance concerns however emerged with very rare, but potentially disastrous thrombotic complications following vaccination with ChAdOx1. Platelet factor-4 antibody mediated vaccine-induced immune thrombotic thrombocytopenia (VITT) was described as an underlying mechanism of these thrombotic events. Recent work moreover suggests that mechanisms of immunothrombosis including neutrophil extracellular trap (NET) formation might be critical for thrombogenesis during VITT. In this study, we investigated blood and thrombus specimens of a female patient who suffered severe stroke due to VITT after vaccination with ChAdOx1 in comparison to 13 control stroke patients with similar clinical characteristics. We analyzed cerebral thrombi using histological examination, staining of complement factors, NET-markers, DNase and LL-37. In blood samples at the hyper-acute phase of stroke and 7 days later, we determined cell-free DNA, myeloperoxidase-histone complexes, DNase activity, myeloperoxidase activity, LL-37 and inflammatory cytokines. NET markers were identified in thrombi of all patients. Interestingly, the thrombus of the VITT-patient exclusively revealed complement factors and high amounts of DNase and LL-37. High DNase activity was also measured in blood, implying a disturbed NET-regulation. Furthermore, serum of the VITT-patient inhibited reactive oxygen species-dependent NET-release by phorbol-myristate-acetate to a lesser degree compared to controls, indicating either less efficient NET-inhibition or enhanced NET-induction in the blood of the VITT-patient. Additionally, the changes in specific cytokines over time were emphasized in the VITT-patient as well. In conclusion, insufficient resolution of NETs, e.g. by endogenous DNases or protection of NETs against degradation by embedded factors like the antimicrobial peptide LL-37 might thus be an important factor in the pathology of VITT besides increased NET-formation. On the basis of these findings, we discuss the potential implications of the mechanisms of disturbed NETs-degradation for diagnostic and therapeutic approaches in VITT-related thrombogenesis, other auto-immune disorders and beyond.
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Affiliation(s)
- Nicole de Buhr
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany.,Research Center for Emerging Infections and Zoonoses (RIZ), University of Veterinary Medicine Hannover, Hannover, Germany
| | - Tristan Baumann
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Leonie Fingerhut
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany.,Research Center for Emerging Infections and Zoonoses (RIZ), University of Veterinary Medicine Hannover, Hannover, Germany.,Clinic for Horses, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Rabea Imker
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany.,Research Center for Emerging Infections and Zoonoses (RIZ), University of Veterinary Medicine Hannover, Hannover, Germany
| | - Marita Meurer
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany.,Research Center for Emerging Infections and Zoonoses (RIZ), University of Veterinary Medicine Hannover, Hannover, Germany
| | - Friedrich Götz
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Paul Bronzlik
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Mark P Kühnel
- Institute of Pathology, Hannover Medical School, Hannover, Germany.,Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Danny D Jonigk
- Institute of Pathology, Hannover Medical School, Hannover, Germany.,Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Johanna Ernst
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Andrei Leotescu
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Maria M Gabriel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Hans Worthmann
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ralf Lichtinghagen
- Institute of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Maren von Köckritz-Blickwede
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany.,Research Center for Emerging Infections and Zoonoses (RIZ), University of Veterinary Medicine Hannover, Hannover, Germany
| | - Christine S Falk
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | | | - Ramona Schuppner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Gerrit M Grosse
- Department of Neurology, Hannover Medical School, Hannover, Germany
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18
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Mani A, Ojha V. Thromboembolism after Covid-19 vaccination: a systematic review of such events in 286 patients. Ann Vasc Surg 2022; 84:12-20.e1. [PMID: 35568325 PMCID: PMC9093198 DOI: 10.1016/j.avsg.2022.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/07/2022] [Accepted: 05/01/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Development of vaccines with high efficacy against Covid-19 disease has ushered a new ray of hope in the fight against the pandemic. Thromboembolic events have been reported after administration of vaccines. We aim to systematically review thromboembolic events reported after Covid-19 vaccination. METHODS The available literature was systematically screened for available data on thromboembolic events post Covid-19 vaccination. Data was extracted from selected studies and analysed for site of thromboembolism as well as other risk factors. All data was pooled to determine cumulative incidence of thromboembolism at various sites post vaccination. RESULTS A total of 20 studies were selected for final analysis. The mean age of the population was 48.5 ± 15.4 years (females- 67.4%). Mean time to event post vaccination was 10.8 ± 7.2 days. Venous thrombosis(74.8%, n=214/286) was more common than arterial thrombosis ( 27.9%,n=80/286). Cerebral sinus thrombosis was most common manifestation (28.3%,n=81/286) of venous thrombosis followed by deep vein thrombosis(19.2%,n=49/254). Myocardial infarction was common (20.1%,n=55/274) in patients with arterial thrombosis followed by ischemic stroke (8.02%,n=22/274). Concurrent thrombosis at multiple sites was noted in 15.4% patients. Majority of patients had thrombocytopenia (49%) and anti-platelet factor 4 antibodies (78.6%). Thromboembolic events were mostly reported after Astra-Zeneca vaccine (93.7%). Cerebral sinus thrombosis was most common amongst thromboembolic events reported after Astra-Zeneca vaccine. Amongst the reported cases, mortality was noted in 29.9% patients. CONCLUSION Thromboembolic events can occur after Covid-19 vaccination, most commonly after Astra Zeneca vaccine. Cerebral sinus thrombosis is the most common manifestation noted in vaccinated individuals.
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Affiliation(s)
- Avinash Mani
- Department of Cardiology, Sri Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Vineeta Ojha
- Department of Cardiovascular Radiology & Endovascular Interventions, All India Institute of Medical Sciences, New Delhi-110029, India.
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19
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Li M, Wang H, Tian L, Pang Z, Yang Q, Huang T, Fan J, Song L, Tong Y, Fan H. COVID-19 vaccine development: milestones, lessons and prospects. Signal Transduct Target Ther 2022; 7:146. [PMID: 35504917 PMCID: PMC9062866 DOI: 10.1038/s41392-022-00996-y] [Citation(s) in RCA: 147] [Impact Index Per Article: 73.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 12/15/2022] Open
Abstract
With the constantly mutating of SARS-CoV-2 and the emergence of Variants of Concern (VOC), the implementation of vaccination is critically important. Existing SARS-CoV-2 vaccines mainly include inactivated, live attenuated, viral vector, protein subunit, RNA, DNA, and virus-like particle (VLP) vaccines. Viral vector vaccines, protein subunit vaccines, and mRNA vaccines may induce additional cellular or humoral immune regulations, including Th cell responses and germinal center responses, and form relevant memory cells, greatly improving their efficiency. However, some viral vector or mRNA vaccines may be associated with complications like thrombocytopenia and myocarditis, raising concerns about the safety of these COVID-19 vaccines. Here, we systemically assess the safety and efficacy of COVID-19 vaccines, including the possible complications and different effects on pregnant women, the elderly, people with immune diseases and acquired immunodeficiency syndrome (AIDS), transplant recipients, and cancer patients. Based on the current analysis, governments and relevant agencies are recommended to continue to advance the vaccine immunization process. Simultaneously, special attention should be paid to the health status of the vaccines, timely treatment of complications, vaccine development, and ensuring the lives and health of patients. In addition, available measures such as mix-and-match vaccination, developing new vaccines like nanoparticle vaccines, and optimizing immune adjuvant to improve vaccine safety and efficacy could be considered.
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Affiliation(s)
- Maochen Li
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, China
| | - Han Wang
- Laboratory for Clinical Immunology, Harbin Children's Hospital, Harbin, China
| | - Lili Tian
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, China
| | - Zehan Pang
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, China
| | - Qingkun Yang
- College of Materials Science and Engineering, Beijing University of Chemical Technology, Beijing, China
| | - Tianqi Huang
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, China
| | - Junfen Fan
- Institute of Cerebrovascular Disease Research and Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Lihua Song
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, China.
| | - Yigang Tong
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, China. .,Beijing Advanced Innovation Center for Soft Matter Science and Engineering, Beijing University of Chemical Technology, Beijing, China.
| | - Huahao Fan
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, China.
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20
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Tews HC, Driendl SM, Kandulski M, Buechler C, Heiss P, Stöckert P, Heissner K, Paulus MG, Kunst C, Müller M, Schmid S. SARS-CoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia with Venous Thrombosis, Pulmonary Embolism, and Adrenal Haemorrhage: A Case Report with Literature Review. Vaccines (Basel) 2022; 10:vaccines10040595. [PMID: 35455346 PMCID: PMC9029242 DOI: 10.3390/vaccines10040595] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 12/11/2022] Open
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) with venous thrombosis is a rare complication of SARS-CoV-2 vaccination with ChAdOx1 (AstraZeneca) and AD26.COV2.S (Johnson & Johnson, New Brunswick, NJ, USA) associated with high mortality. At present, there are no known differences in the pathophysiology or risk factors of VITT with the AstraZeneca vaccine (ChAdOx1) compared with the Johnson & Johnson vaccine (AD26.COV2.S). Herein, we present the case of a healthy 39-year-old patient with VITT after having received the vaccine Ad26.COV2.S. Ten days after vaccination, the patient developed a deep vein thrombosis and subsequent pulmonary embolism. A computed tomography scan of the abdomen showed adrenal gland bleeding and an adrenocorticotrophic hormone stimulation test diagnosed adrenal insufficiency. Therapy with intravenous immunoglobulin, argatroban and hydrocortisone was initiated immediately after diagnosis. The patient left the hospital 22 days after admission with the diagnosis of adrenal insufficiency but otherwise in good health. To the best of our knowledge, five cases of VITT and adrenal bleeding have been described to date in the literature but the presented case was the first to occur after immunisation with the vaccine of Johnson & Johnson. In summary, VITT-associated adrenal dysfunction is a very rare complication of vaccination with an adenoviral vector-based COVID-19 vaccine.
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Affiliation(s)
- Hauke Christian Tews
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (S.M.D.); (M.K.); (C.B.); (P.S.); (K.H.); (C.K.); (M.M.); (S.S.)
- Correspondence: ; Tel.: +49-941-9441-7164
| | - Sarah M. Driendl
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (S.M.D.); (M.K.); (C.B.); (P.S.); (K.H.); (C.K.); (M.M.); (S.S.)
| | - Melanie Kandulski
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (S.M.D.); (M.K.); (C.B.); (P.S.); (K.H.); (C.K.); (M.M.); (S.S.)
| | - Christa Buechler
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (S.M.D.); (M.K.); (C.B.); (P.S.); (K.H.); (C.K.); (M.M.); (S.S.)
| | - Peter Heiss
- Department of Radiology, University Hospital Regensburg, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany;
| | - Petra Stöckert
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (S.M.D.); (M.K.); (C.B.); (P.S.); (K.H.); (C.K.); (M.M.); (S.S.)
| | - Klaus Heissner
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (S.M.D.); (M.K.); (C.B.); (P.S.); (K.H.); (C.K.); (M.M.); (S.S.)
| | - Michael G. Paulus
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany;
| | - Claudia Kunst
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (S.M.D.); (M.K.); (C.B.); (P.S.); (K.H.); (C.K.); (M.M.); (S.S.)
| | - Martina Müller
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (S.M.D.); (M.K.); (C.B.); (P.S.); (K.H.); (C.K.); (M.M.); (S.S.)
| | - Stephan Schmid
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (S.M.D.); (M.K.); (C.B.); (P.S.); (K.H.); (C.K.); (M.M.); (S.S.)
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21
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Vaccine-induced thrombotic thrombocytopenia: Effect of E3 gene elimination from ds-DNA adenovirus vector? Med Hypotheses 2022. [DOI: 10.1016/j.mehy.2022.110864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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22
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Greinacher A, Schönborn L, Siegerist F, Steil L, Palankar R, Handtke S, Reder A, Thiele T, Aurich K, Methling K, Lalk M, Völker U, Endlich N. Pathogenesis of vaccine-induced immune thrombotic thrombocytopenia (VITT). Semin Hematol 2022; 59:97-107. [PMID: 35512907 PMCID: PMC8863951 DOI: 10.1053/j.seminhematol.2022.02.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 02/16/2022] [Indexed: 02/06/2023]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT; synonym, thrombosis with thrombocytopenia syndrome, is associated with high-titer immunoglobulin G antibodies directed against platelet factor 4 (PF4). These antibodies activate platelets via platelet FcγIIa receptors, with platelet activation greatly enhanced by PF4. Here we summarize the current concepts in the pathogenesis of VITT. We first address parallels between heparin-induced thrombocytopenia and VITT, and provide recent findings on binding of PF4 to adenovirus particles and non-assembled adenovirus proteins in the 2 adenovirus vector-based COVID-19 vaccines, ChAdOx1 nCoV-19 and Ad26.COV2.S. Further, we discuss the potential role of vaccine constituents such as glycosaminoglycans, EDTA, polysorbate 80, human cell-line proteins and nucleotides as potential binding partners of PF4. The immune response towards PF4 in VITT is likely triggered by a proinflammatory milieu. Human cell-line proteins, non-assembled virus proteins, and potentially EDTA may contribute to the proinflammatory state. The transient nature of the immune response towards PF4 in VITT makes it likely that-as in heparin-induced thrombocytopenia -marginal zone B cells are key for antibody production. Once high-titer anti-PF4 antibodies have been formed 5 to 20 days after vaccination, they activate platelets and granulocytes. Activated granulocytes undergo NETosis and the released DNA also forms complexes with PF4, which fuels the Fcγ receptor-dependent cell activation process, ultimately leading to massive thrombin generation. Finally, we summarize our initial observations indicating that VITT-like antibodies might also be present in rare patients with recurrent venous and arterial thrombotic complications, independent of vaccination.
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Affiliation(s)
- Andreas Greinacher
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany,Corresponding author: Prof. Dr Andreas Greinacher, Institut für Transfusions medizin, Universitätsmedizin Greifswald, Sauerbruchstraße, D-17489 Greifswald, Germany. Tel: +49 383 486 5482; fax: +49 383 486 5489
| | - Linda Schönborn
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Florian Siegerist
- Institute for Anatomy and Cell Biology, University Medicine Greifswald, Greifswald, Germany
| | - Leif Steil
- Interfaculty Institute of Genetics and Functional Genomics, Department Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Raghavendra Palankar
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Stefan Handtke
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Alexander Reder
- Interfaculty Institute of Genetics and Functional Genomics, Department Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Konstanze Aurich
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Karen Methling
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Michael Lalk
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Uwe Völker
- Interfaculty Institute of Genetics and Functional Genomics, Department Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Nicole Endlich
- Institute for Anatomy and Cell Biology, University Medicine Greifswald, Greifswald, Germany
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23
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Kim AY, Woo W, Yon DK, Lee SW, Yang JW, Kim JH, Park S, Koyanagi A, Kim MS, Lee S, Shin JI, Smith L. Thrombosis patterns and clinical outcome of COVID-19 vaccine-induced immune thrombotic thrombocytopenia: A Systematic Review and Meta-Analysis. Int J Infect Dis 2022; 119:130-139. [PMID: 35339716 PMCID: PMC8942584 DOI: 10.1016/j.ijid.2022.03.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/06/2022] [Accepted: 03/17/2022] [Indexed: 01/06/2023] Open
Abstract
Objectives To meta-analyse the clinical manifestations, diagnosis, treatment, and mortality of vaccine-induced immune thrombotic thrombocytopenia (VITT) after adenoviral vector vaccination. Methods Eighteen studies of VITT after ChAdOx1 nCoV-19 or Ad26.COV2.S vaccine administration were reviewed from PubMed, Scopus, Embase, and Web of Science. The meta-analysis estimated the summary effects and between-study heterogeneity regarding the incidence, manifestations, sites of thrombosis, diagnostic findings, and clinical outcomes. Results The incidence of total venous thrombosis after ChAdOx1 nCoV-19 vaccination was 28 (95% CI 12-52, I2=100%) per 100,000 doses administered. Of 664 patients included in the quantitative analysis (10 studies), the mean age of patients with VITT was 45.6 years (95% CI 43.8-47.4, I2=57%), with a female predominance (70%). Cerebral venous thrombosis (CVT), deep vein thrombosis (DVT)/pulmonary thromboembolism (PE), and splanchnic vein thrombosis occurred in 54%, 36%, and 19% of patients with VITT, respectively. The pooled incidence rate of CVT after ChAdOx1 nCoV-19 vaccination (23 per 100,000 person-years) was higher than that reported in the pre-pandemic general population (0.9 per 100,000 person-years). Intracranial haemorrhage and extracranial thrombosis accompanied 47% and 33% of all patients with CVT, respectively. The antiplatelet factor 4 antibody positivity rate was 91% (95% CI 88-94, I2=0%) and the overall mortality was 32% (95% CI 24-41, I2=69%), and no significant difference was observed between heparin- and non-heparin-based anticoagulation treatments (risk ratio 0.84, 95% CI 0.47-1.50, I2=0%). Conclusions Patients with VITT after SARS-CoV-2 vaccination most frequently presented with CVT following DVT/PE and splanchnic vein thrombosis, and about one-third of patients had a fatal outcome. This meta-analysis should provide a better understanding of VITT and assist clinicians in identifying VITT early to improve outcomes and optimise management.
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Affiliation(s)
- Ah Young Kim
- Division of Pediatric Cardiology, Department of Pediatrics, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea; Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Wongi Woo
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Keon Yon
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Seung Won Lee
- Department of Data Science, Sejong University College of Software Convergence, Seoul, South Korea
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Ji Hong Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Seoyeon Park
- Yonsei University College of Medicine, Seoul, South Korea
| | - Ai Koyanagi
- Parc Sanitari Sant Joan de Deu/CIBERSAM, Universitat de Barcelona, Fundacio Sant Joan de Deu, Sant Boi de Llobregat, Barcelona, Spain; ICREA, Pg. Lluis Companys 23, Barcelona, Spain
| | - Min Seo Kim
- Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Samsung Medical Center, Seoul, Republic of Korea
| | - Sungsoo Lee
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.
| | - Lee Smith
- Cambridge Centre for Health, Performance, and Wellbeing, Anglia Ruskin University, Cambridge, UK
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24
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Alban S, Neupane S, Girreser U, Sönnichsen FD, Greinacher A. The COVID-19 vaccine ChAdOx1-S is not contaminated with sulfated glycosaminoglycans. J Thromb Haemost 2022; 20:777-780. [PMID: 34971474 PMCID: PMC9906281 DOI: 10.1111/jth.15633] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 12/30/2021] [Accepted: 12/30/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Susanne Alban
- Pharmazeutisches Institut, Abteilung Pharmazeutische Biologie, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Sandesh Neupane
- Pharmazeutisches Institut, Abteilung Pharmazeutische Biologie, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Ulrich Girreser
- Pharmazeutisches Institut, Abteilung Pharmazeutische Chemie, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Frank D Sönnichsen
- Otto Diels Institut für Organische Chemie, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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25
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Warkentin TE. Platelet-activating anti-PF4 disorders: an overview. Semin Hematol 2022; 59:59-71. [DOI: 10.1053/j.seminhematol.2022.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/11/2022]
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26
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Ahmed SH, Shaikh TG, Waseem S, Qadir NA, Yousaf Z, Ullah I. Vaccine-induced thrombotic thrombocytopenia following coronavirus vaccine: A narrative review. Ann Med Surg (Lond) 2022; 73:102988. [PMID: 34745596 PMCID: PMC8556865 DOI: 10.1016/j.amsu.2021.102988] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 12/26/2022] Open
Abstract
The novel coronavirus pandemic has taken a toll on the global healthcare systems and economy. Safety precautions, along with vaccination, are the most effective preventive measures. The global vaccination program against COVID-19 has dramatically reduced the number of deaths and cases. However, the incidence of thrombotic events and thrombocytopenia post-COVID-19 vaccination known as vaccine-induced thrombotic thrombocytopenia has raised safety concerns. This has led to an element of vaccine hesitancy. The exact mechanism for vaccine-induced thrombotic thrombocytopenia is unknown. Although the incidence of thrombosis associated with COVID-19 vaccination is low, it still requires attention, especially in older people, smokers, and people with preexisting comorbidities. This study aims to review the pathophysiology, diagnosis, and management of vaccine-induced thrombotic thrombocytopenia, to provide a concise and comprehensive update.
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Affiliation(s)
| | | | | | | | - Zohaib Yousaf
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
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27
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Inhibition of NADPH oxidase blocks NETosis and reduces thrombosis in heparin-induced thrombocytopenia. Blood Adv 2021; 5:5439-5451. [PMID: 34478504 PMCID: PMC9153028 DOI: 10.1182/bloodadvances.2020003093] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 05/24/2021] [Indexed: 12/23/2022] Open
Abstract
ROS generation is essential for thrombus formation in HIT. NOX2 inhibition prevents thrombus formation in a murine model of HIT.
Heparin-induced thrombocytopenia (HIT) is associated with severe and potentially lethal thrombotic complications. NETosis was recently shown to be an important driver of thrombosis in HIT. We investigated the role of reactive oxygen species (ROS) and nicotinamide adenine dinucleotide phosphate (NADPH) oxidase 2 (NOX2) and their contributions to thrombus development in HIT. We showed that neutrophil activation by HIT immune complexes induced ROS-dependent NETosis. Analysis of thrombi formed in a microfluidics system showed ROS production in both platelets and neutrophils, and abundant neutrophil extracellular traps (NETs) and ROS distributed throughout the clot. Neutrophil-targeted ROS inhibition was sufficient to block HIT-induced NETosis and thrombosis using human blood. Inhibition of NOX2 with diphenyleneiodonium chloride or GSK2795039 abrogated HIT-induced thrombi in vivo using FcγRIIa+/hPF4+-transgenic mice. Thrombocytopenia in mice remained unaffected by ROS inhibition. Increased ROS production in activated neutrophils was also confirmed using fresh blood from patients with active HIT. Our findings show that ROS and NOX2 play a crucial role in NETosis and thrombosis in HIT. This enhances our understanding of the processes driving thrombosis in HIT and identifies NOX2 as a potential new therapeutic target for antithrombotic treatment of HIT.
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28
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Corica B, Cacciani A, Cangemi R, Visentini M, Recchia F, Grillo R, Vano M, Sperduti N, Cincione A, Buoninfante G, Pulcinelli F, Chistolini A, De Santis A, Flego D, Romiti GF, Basili S, Stefanini L. Clinical course, management, and platelet activity assessment of splanchnic VITT: A case report. Thromb Res 2021; 208:14-17. [PMID: 34673368 PMCID: PMC8513518 DOI: 10.1016/j.thromres.2021.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/14/2021] [Accepted: 10/11/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Bernadette Corica
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | | | - Roberto Cangemi
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Marcella Visentini
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Fabrizio Recchia
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Rosalba Grillo
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Marco Vano
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Nicolò Sperduti
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Alessandro Cincione
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Giovanni Buoninfante
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Fabio Pulcinelli
- Department of Experimental Medicine, Sapienza - University of Rome, Rome, Italy
| | - Antonio Chistolini
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Adriano De Santis
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Davide Flego
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy.
| | - Lucia Stefanini
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
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29
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Roberge G, Scarvelis D. Long-term anti-PF4 persistence in autoimmune heparin-induced thrombocytopenia: A glimpse into the natural history of vaccine-induced immune thrombotic thrombocytopenia. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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30
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Bilotta C, Perrone G, Adelfio V, Spatola GF, Uzzo ML, Argo A, Zerbo S. COVID-19 Vaccine-Related Thrombosis: A Systematic Review and Exploratory Analysis. Front Immunol 2021; 12:729251. [PMID: 34912330 PMCID: PMC8666479 DOI: 10.3389/fimmu.2021.729251] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/08/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction The World Health Organization declared the coronavirus disease 2019 (COVID-19) pandemic on March 11, 2020. Two vaccine types were developed using two different technologies: viral vectors and mRNA. Thrombosis is one of the most severe and atypical adverse effects of vaccines. This study aimed to analyze published cases of thrombosis after COVID-19 vaccinations to identify patients' features, potential pathophysiological mechanisms, timing of appearance of the adverse events, and other critical issues. Materials and Methods We performed a systematic electronic search of scientific articles regarding COVID-19 vaccine-related thrombosis and its complications on the PubMed (MEDLINE) database and through manual searches. We selected 10 out of 50 articles from February 1 to May 5, 2021 and performed a descriptive analysis of the adverse events caused by the mRNA-based Pfizer and Moderna vaccines and the adenovirus-based AstraZeneca vaccine. Results In the articles on the Pfizer and Moderna vaccines, the sample consisted of three male patients with age heterogeneity. The time from vaccination to admission was ≤3 days in all cases; all patients presented signs of petechiae/purpura at admission, with a low platelet count. In the studies on the AstraZeneca vaccine, the sample consisted of 58 individuals with a high age heterogeneity and a high female prevalence. Symptoms appeared around the ninth day, and headache was the most common symptom. The platelet count was below the lower limit of the normal range. All patients except one were positive for PF4 antibodies. The cerebral venous sinus was the most affected site. Death was the most prevalent outcome in all studies, except for one study in which most of the patients remained alive. Discussion Vaccine-induced thrombotic thrombocytopenia (VITT) is an unknown nosological phenomenon secondary to inoculation with the COVID-19 vaccine. Several hypotheses have been formulated regarding its physiopathological mechanism. Recent studies have assumed a mechanism that is assimilable to heparin-induced thrombocytopenia, with protagonist antibodies against the PF4-polyanion complex. Viral DNA has a negative charge and can bind to PF4, causing VITT. New experimental studies have assumed that thrombosis is related to a soluble adenoviral protein spike variant, originating from splicing events, which cause important endothelial inflammatory events, and binding to endothelial cells expressing ACE2. Conclusion Further studies are needed to better identify VITT's pathophysiological mechanisms and genetic, demographic, or clinical predisposition of high-risk patients, to investigate the correlation of VITT with the different vaccine types, and to test the significance of the findings.
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Affiliation(s)
- Clio Bilotta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Giulio Perrone
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Valeria Adelfio
- Department of Economics, Business and Statistics, University of Palermo, Palermo, Italy
| | - Giovanni Francesco Spatola
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Maria Laura Uzzo
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Antonina Argo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Stefania Zerbo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
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31
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Elrashdy F, Tambuwala MM, Hassan SS, Adadi P, Seyran M, Abd El-Aziz TM, Rezaei N, Lal A, Aljabali AAA, Kandimalla R, Bazan NG, Azad GK, Sherchan SP, Choudhury PP, Serrano-Aroca Á, Takayama K, Chauhan G, Pizzol D, Barh D, Panda PK, Mishra YK, Palù G, Lundstrom K, Redwan EM, Uversky VN. Autoimmunity roots of the thrombotic events after COVID-19 vaccination. Autoimmun Rev 2021; 20:102941. [PMID: 34508917 PMCID: PMC8426137 DOI: 10.1016/j.autrev.2021.102941] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 06/06/2021] [Indexed: 02/03/2023]
Abstract
Although vaccination represents the most promising way to stop or contain the coronavirus disease 2019 (COVID-19) pandemic and safety and effectiveness of available vaccines were proven, a small number of individuals who received anti-SARS-CoV-2 vaccines developed a prothrombotic syndrome. Vaccine-induced immune thrombotic thrombocytopenia (VITT) can be triggered by the adenoviral vector-based vaccine, whereas lipid nanoparticle-mRNA-based vaccines can induce rare cases of deep vein thrombosis (DVT). Although the main pathogenic mechanisms behind this rare phenomenon have not yet been identified, both host and vaccine factors might be involved, with pathology at least in part being related to the vaccine-triggered autoimmune reaction. In this review, we are considering some aspects related to pathogenesis, major risk factors, as well as peculiarities of diagnosis and treatment of this rare condition.
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Affiliation(s)
- Fatma Elrashdy
- Department of Endemic Medicine and Hepatogastroenterology, Kasr Alainy, Cairo University, Cairo, Egypt.
| | - Murtaza M Tambuwala
- School of Pharmacy and Pharmaceutical Sciences, Ulster University, Coleraine, BT52 1SA, Northern Ireland, United Kingdom.
| | - Sk Sarif Hassan
- Department of Mathematics, Pingla Thana Mahavidyalaya, Maligram, 722140 Paschim Medinipur, West Bengal, India
| | - Parise Adadi
- Department of Food Science, University of Otago, Dunedin, New Zealand
| | - Murat Seyran
- Doctoral Student in Natural and Technical Sciences (SPL 44), University of Vienna, Währinger Straße, A-1090 Vienna, Austria.
| | - Tarek Mohamed Abd El-Aziz
- Zoology Department, Faculty of Science, Minia University, El-Minia 61519, Egypt; Department of Cellular and Integrative Physiology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA.
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Stockholm, Sweden
| | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, USA
| | - Alaa A A Aljabali
- Department of Pharmaceutics and Pharmaceutical Technology, Yarmouk University, Irbid 21163, P. O. BOX 566, Jordan.
| | - Ramesh Kandimalla
- Applied Biology, CSIR-Indian Institute of Chemical Technology, Uppal Road, Tarnaka, Hyderabad 500007, India; Department of Biochemistry, Kakatiya Medical College, Warangal, India
| | - Nicolas G Bazan
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, Louisiana, 70112, USA.
| | | | - Samendra P Sherchan
- Department of Environmental Health Sciences, Tulane University, New Orleans, LA 70112, USA.
| | - Pabitra Pal Choudhury
- Applied Statistics Unit, Indian Statistical Institute, Kolkata, 700108, West Bengal, India
| | - Ángel Serrano-Aroca
- Biomaterials and Bioengineering Lab, Centro de Investigación Traslacional San Alberto Magno, Universidad Católica de Valencia San Vicente Mártir, c/Guillem de Castro 94, Valencia 46001, Spain.
| | - Kazuo Takayama
- Center for iPS Cell Research and Application (CiRA), Kyoto University, Kyoto 606-8507, Japan.
| | - Gaurav Chauhan
- School of Engineering and Sciences, Tecnológico de Monterrey, Av. Eugenio Garza Sada 2501 Sur, 64849 Monterrey, Nuevo León, Mexico.
| | - Damiano Pizzol
- Italian Agency for Development Cooperation -, Khartoum, Sudan Street 33, Al Amarat, Sudan
| | - Debmalya Barh
- Institute of Integrative Omics and Applied Biotechnology (IIOAB), Nonakuri, Purba Medinipur, WB-721172, India; and Departamento de Genética, Ecologia e Evolução, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, Brazil.
| | - Pritam Kumar Panda
- Condensed Matter Theory Group, Materials Theory Division, Department of Physics and Astronomy, Uppsala University, Box 516, SE-751 20 Uppsala, Sweden.
| | - Yogendra K Mishra
- University of Southern Denmark, Mads Clausen Institute, NanoSYD, Alsion 2, 6400 Sønderborg, Denmark.
| | - Giorgio Palù
- Department of Molecular Medicine, University of Padova, Italy.
| | | | - Elrashdy M Redwan
- Biological Science Department, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Vladimir N Uversky
- Department of Molecular Medicine, University of South Florida, Tampa, FL, United States.
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32
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Devi A, Doley R. Neutralization of Daboxin P activities by rationally designed aptamers. Toxicon 2021; 203:93-103. [PMID: 34619285 DOI: 10.1016/j.toxicon.2021.09.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
Inefficacy and associated risks of current antivenom has raised the need for alternative approaches of snakebite management. Aptamers are one such alternative which is being pursued for therapeutic interventions as well as for design of diagnostic kits due to its high specificity. Present study focussed on designing and validating nucleic acid aptamers against snake venom PLA2, a hydrolytic enzyme present in all venomous snakes. The aptamers were designed by adding nucleic acid chain on the surface of Daboxin P, a major PLA2 enzyme of Daboia russelii venom. Binding characteristics of the aptamers were confirmed by docking to Daboxin P as well as acidic and basic PLA2s from different snake species using in silico docking. The aptamers folded into different tertiary structures and bound to the active and Ca2+ binding site of PLA2 enzymes. Molecular dynamics simulation analysis of Daboxin P-aptamer complexes showed that the complexes were stable in an aqueous environment. The electrophoretic mobility shift assay further confirmed the binding of the synthetic aptamers to Daboxin P and other snake venom PLA2 enzymes. The aptamers inhibited the sPLA2 activity with an IC50 value ranging between 0.52 μM and 0.77 μM as well as the anticoagulant activity of Daboxin P. The aptamers could also inhibit the PLA2 activity of Echis carinatus crude venom and anti-coagulant activity of Bungarus caeruleus crude venom, members of big four snakes. However, the aptamers didn't inhibit fibrinogenolytic or proteolytic activity of big four venom as well as the coagulation and hemolytic activities. Thus, aptamers can be rationally designed to inhibit the biochemical and biological activities of snake venom proteins.
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Affiliation(s)
- Arpita Devi
- Molecular Toxinology Laboratory, Department of Molecular Biology and Biotechnology, Tezpur University, Napaam, Tezpur, Assam, India
| | - Robin Doley
- Molecular Toxinology Laboratory, Department of Molecular Biology and Biotechnology, Tezpur University, Napaam, Tezpur, Assam, India.
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Insights in ChAdOx1 nCov-19 Vaccine-induced Immune Thrombotic Thrombocytopenia (VITT). Blood 2021; 138:2256-2268. [PMID: 34587242 PMCID: PMC8483989 DOI: 10.1182/blood.2021013231] [Citation(s) in RCA: 187] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/13/2021] [Indexed: 11/20/2022] Open
Abstract
SARS-CoV-2 vaccine ChAdOx1 nCov-19 (AstraZeneca) causes a thromboembolic complication termed vaccine-induced immune thrombotic thrombocytopenia (VITT). Using biophysical techniques, mouse models and analysis of VITT patient samples we identified determinants of this vaccine-induced adverse reaction. Super-resolution microscopy visualized vaccine components forming antigenic complexes with platelet factor 4 (PF4) on platelet surfaces to which anti-PF4 antibodies obtained from VITT patients bound. PF4/vaccine complex formation was charge-driven and increased by addition of DNA. Proteomics identified substantial amounts of virus production-derived T-REx HEK293 proteins in the EDTA-containing vaccine. Injected vaccine increased vascular leakage in mice leading to systemic dissemination of vaccine components known to stimulate immune responses. Together, PF4/vaccine complex formation and the vaccine-stimulated proinflammatory milieu trigger a pronounced B cell response that results in the formation of high-avidity anti-PF4 antibodies in VITT patients. The resulting high-titer anti-PF4 antibodies potently activated platelets in the presence of PF4 or DNA and polyphosphate polyanions. Anti-PF4 VITT patient antibodies also stimulated neutrophils to release NETs in a platelet PF4-dependent manner. Biomarkers of procoagulant NETs were elevated in VITT patient serum, and NETs were visualized in abundance by immunohistochemistry in cerebral vein thrombi obtained from VITT patients. Together, vaccine-induced PF4/adenovirus aggregates and proinflammatory reactions stimulate pathologic anti-PF4 antibody production that drive thrombosis in VITT. The data support a two-step mechanism underlying VITT that resembles the pathogenesis of (autoimmune) heparin-induced thrombocytopenia.
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Arepally GM, Ortel TL. Vaccine-induced immune thrombotic thrombocytopenia: what we know and do not know. Blood 2021; 138:293-298. [PMID: 34323940 PMCID: PMC8172307 DOI: 10.1182/blood.2021012152] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/27/2021] [Indexed: 02/08/2023] Open
Abstract
The development of vaccines to fight COVID-19 has been a remarkable medical achievement. However, this global immunization effort has been complicated by a rare vaccine-related outcome characterized by thrombocytopenia and thrombosis in association with platelet-activating anti-platelet factor 4 antibodies. In this Spotlight, we will discuss the recently described complication of vaccine-induced immune thrombotic thrombocytopenia (VITT) occurring in response to certain COVID-19 vaccines. Although information about this clinical condition is rapidly evolving, we will summarize our current understanding of VITT.
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Affiliation(s)
| | - Thomas L Ortel
- Division of Hematology, Duke University Medical Center, Durham, NC
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Lundstrom K, Barh D, Uhal BD, Takayama K, Aljabali AAA, Abd El-Aziz TM, Lal A, Redwan EM, Adadi P, Chauhan G, Sherchan SP, Azad GK, Rezaei N, Serrano-Aroca Á, Bazan NG, Hassan SS, Panda PK, Pal Choudhury P, Pizzol D, Kandimalla R, Baetas-da-Cruz W, Mishra YK, Palu G, Brufsky AM, Tambuwala MM, Uversky VN. COVID-19 Vaccines and Thrombosis-Roadblock or Dead-End Street? Biomolecules 2021; 11:1020. [PMID: 34356644 PMCID: PMC8301964 DOI: 10.3390/biom11071020] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 12/16/2022] Open
Abstract
Two adenovirus-based vaccines, ChAdOx1 nCoV-19 and Ad26.COV2.S, and two mRNA-based vaccines, BNT162b2 and mRNA.1273, have been approved by the European Medicines Agency (EMA), and are invaluable in preventing and reducing the incidence of coronavirus disease-2019 (COVID-19). Recent reports have pointed to thrombosis with associated thrombocytopenia as an adverse effect occurring at a low frequency in some individuals after vaccination. The causes of such events may be related to SARS-CoV-2 spike protein interactions with different C-type lectin receptors, heparan sulfate proteoglycans (HSPGs) and the CD147 receptor, or to different soluble splice variants of the spike protein, adenovirus vector interactions with the CD46 receptor or platelet factor 4 antibodies. Similar findings have been reported for several viral diseases after vaccine administration. In addition, immunological mechanisms elicited by viral vectors related to cellular delivery could play a relevant role in individuals with certain genetic backgrounds. Although rare, the potential COVID-19 vaccine-induced immune thrombotic thrombocytopenia (VITT) requires immediate validation, especially in risk groups, such as the elderly, chronic smokers, and individuals with pre-existing incidences of thrombocytopenia; and if necessary, a reformulation of existing vaccines.
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Affiliation(s)
| | - Debmalya Barh
- Centre for Genomics and Applied Gene Technology, Institute of Integrative Omics and Applied Biotechnology (IIOAB), Purba Medinipur 721172, India
- Departamento de Genética, Ecologia e Evolução, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Bruce D. Uhal
- Department of Physiology, Michigan State University, East Lansing, MI 48824, USA;
| | - Kazuo Takayama
- Center for iPS Cell Research and Application, Kyoto University, Kyoto 606-8397, Japan;
| | - Alaa A. A. Aljabali
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Yarmouk University, P.O. Box 566, Irbid 21163, Jordan;
| | - Tarek Mohamed Abd El-Aziz
- Zoology Department, Faculty of Science, Minia University, El-Minia 61519, Egypt;
- Department of Cellular and Integrative Physiology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55902, USA;
| | - Elrashdy M. Redwan
- Biological Science Department, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
| | - Parise Adadi
- Department of Food Science, University of Otago, Dunedin 9054, New Zealand;
| | - Gaurav Chauhan
- School of Engineering and Sciences, Tecnológico de Monterrey, Av. Eugenio Garza Sada 2501 Sur, Monterrey 64849, Mexico;
| | - Samendra P. Sherchan
- Department of Environmental Health Sciences, Tulane University, New Orleans, LA 70112, USA;
| | | | - Nima Rezaei
- Research Center for Immunodeficiency, Children’s Medical Center, Tehran University of Medical Sciences, Tehran 1416753955, Iran;
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), 17177 Stockholm, Sweden
| | - Ángel Serrano-Aroca
- Biomaterials and Bioengineering Lab, Centro de Investigación Traslacional San Alberto Magno, Universidad Católica de Valencia San Vicente Mártir, c/Guillem de Castro 94, 46001 Valencia, Spain;
| | - Nicolas G. Bazan
- Neuroscience Center of Excellence, School of Medicine, LSU Health New Orleans, New Orleans, LA 70112, USA;
| | - Sk Sarif Hassan
- Department of Mathematics, Pingla Thana Mahavidyalaya, Maligram 721140, India;
| | - Pritam Kumar Panda
- Condensed Matter Theory Group, Materials Theory Division, Department of Physics and Astronomy, Uppsala University, Box 516, 75120 Uppsala, Sweden;
| | | | - Damiano Pizzol
- Italian Agency for Development Cooperation—Khartoum, Sudan Street 33, Al Amarat 11111, Sudan;
| | - Ramesh Kandimalla
- Applied Biology, CSIR-Indian Institute of Technology, Uppal Road, Tarnaka, Hyderabad 500007, India;
- Department of Biochemistry, Kakatiya Medical College, Warangal 506007, India
| | - Wagner Baetas-da-Cruz
- Translational Laboratory in Molecular Physiology, Centre for Experimental Surgery, College of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-901, Brazil;
| | - Yogendra Kumar Mishra
- Mads Clausen Institute, University of Southern Denmark, NanoSYD, Alsion 2, 6400 Sønderborg, Denmark;
| | - Giorgio Palu
- Department of Molecular Medicine, University of Padova, 35122 Padova, PD, Italy;
| | - Adam M. Brufsky
- UPMC Hillman Cancer Center, Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA;
| | - Murtaza M. Tambuwala
- School of Pharmacy and Pharmaceutical Science, Ulster University, Coleraine BT52 1SA, UK
| | - Vladimir N. Uversky
- Department of Molecular Medicine and USF Health Byrd Alzheimer’s Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
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36
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Novak N, Tordesillas L, Cabanillas B. Adverse rare events to vaccines for COVID-19: From hypersensitivity reactions to thrombosis and thrombocytopenia. Int Rev Immunol 2021; 41:438-447. [PMID: 34251972 PMCID: PMC8290371 DOI: 10.1080/08830185.2021.1939696] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/14/2021] [Accepted: 05/29/2021] [Indexed: 01/18/2023]
Abstract
Vaccines for the prevention of coronavirus disease 2019 (COVID-19) started to be developed since the initiation of the COVID-19 pandemic. Up to now, four vaccines have been authorized by international agencies such as European Medicines Agency (EMA). Two are DNA vaccines (ChAdOx1 nCov-19 and Ad26.COV2.S) and two mRNA vaccines (BNT162b2 and mRNA-1273). The administration of the vaccines has been associated with a strong decrease in the infections by SARS-CoV-2 and deaths associated with it. However, in parallel to these results, some rare adverse events have also been described. In that sense, events of thrombosis, thrombocytopenia, and hemorrhage have been described in close temporal proximity to the administration of the DNA vaccines ChAdOx1 nCov-19 and Ad26.COV2.S, but also mRNA vaccines. Recent scientific reports have been released with updated information on the possible association of thrombotic thrombocytopenia and COVID-19 vaccines. On the other hand, since the initiation of the vaccination campaigns, adverse hypersensitivity reactions have been described after mRNA and DNA vaccines administration for COVID-19. Although globally these adverse events are rare, a high proportion of the world population will be exposed to these vaccines. For that reason, their safety and tolerance should be carefully considered. In this review, we provide an updated review of the last scientific findings that can explain the rare side effects that the vaccines for COVID-19 can produce.
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Affiliation(s)
- Natalija Novak
- Department of Dermatology and Allergy, University Hospital, Bonn, Germany
| | - Leticia Tordesillas
- Department of Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Beatriz Cabanillas
- Department of Allergy, Research Institute Hospital 12 de Octubre, Madrid, Spain
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37
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Dickhout A, Kaczor DM, Heinzmann ACA, Brouns SLN, Heemskerk JWM, van Zandvoort MAMJ, Koenen RR. Rapid Internalization and Nuclear Translocation of CCL5 and CXCL4 in Endothelial Cells. Int J Mol Sci 2021; 22:ijms22147332. [PMID: 34298951 PMCID: PMC8305033 DOI: 10.3390/ijms22147332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/27/2021] [Accepted: 07/02/2021] [Indexed: 11/16/2022] Open
Abstract
The chemokines CCL5 and CXCL4 are deposited by platelets onto endothelial cells, inducing monocyte arrest. Here, the fate of CCL5 and CXCL4 after endothelial deposition was investigated. Human umbilical vein endothelial cells (HUVECs) and EA.hy926 cells were incubated with CCL5 or CXCL4 for up to 120 min, and chemokine uptake was analyzed by microscopy and by ELISA. Intracellular calcium signaling was visualized upon chemokine treatment, and monocyte arrest was evaluated under laminar flow. Whereas CXCL4 remained partly on the cell surface, all of the CCL5 was internalized into endothelial cells. Endocytosis of CCL5 and CXCL4 was shown as a rapid and active process that primarily depended on dynamin, clathrin, and G protein-coupled receptors (GPCRs), but not on surface proteoglycans. Intracellular calcium signals were increased after chemokine treatment. Confocal microscopy and ELISA measurements in cell organelle fractions indicated that both chemokines accumulated in the nucleus. Internalization did not affect leukocyte arrest, as pretreatment of chemokines and subsequent washing did not alter monocyte adhesion to endothelial cells. Endothelial cells rapidly and actively internalize CCL5 and CXCL4 by clathrin and dynamin-dependent endocytosis, where the chemokines appear to be directed to the nucleus. These findings expand our knowledge of how chemokines attract leukocytes to sites of inflammation.
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Affiliation(s)
- Annemiek Dickhout
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, The Netherlands; (A.D.); (D.M.K.); (A.C.A.H.); (S.L.N.B.); (J.W.M.H.)
| | - Dawid M. Kaczor
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, The Netherlands; (A.D.); (D.M.K.); (A.C.A.H.); (S.L.N.B.); (J.W.M.H.)
| | - Alexandra C. A. Heinzmann
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, The Netherlands; (A.D.); (D.M.K.); (A.C.A.H.); (S.L.N.B.); (J.W.M.H.)
| | - Sanne L. N. Brouns
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, The Netherlands; (A.D.); (D.M.K.); (A.C.A.H.); (S.L.N.B.); (J.W.M.H.)
| | - Johan W. M. Heemskerk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, The Netherlands; (A.D.); (D.M.K.); (A.C.A.H.); (S.L.N.B.); (J.W.M.H.)
| | - Marc A. M. J. van Zandvoort
- Department of Genetics and Cell Biology, Molecular Cell Biology, School for Oncology and Developmental Biology, Maastricht University, 6229 ER Maastricht, The Netherlands;
- Institute for Molecular Cardiovascular Research IMCAR, RWTH Aachen University, 52074 Aachen, Germany
| | - Rory R. Koenen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, 6229 ER Maastricht, The Netherlands; (A.D.); (D.M.K.); (A.C.A.H.); (S.L.N.B.); (J.W.M.H.)
- Institute for Cardiovascular Prevention (IPEK), LMU Munich, 80336 Munich, Germany
- Correspondence:
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38
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Mohseni Afshar Z, Babazadeh A, Janbakhsh A, Afsharian M, Saleki K, Barary M, Ebrahimpour S. Vaccine-induced immune thrombotic thrombocytopenia after vaccination against Covid-19: A clinical dilemma for clinicians and patients. Rev Med Virol 2021; 32:e2273. [PMID: 34197678 PMCID: PMC8420499 DOI: 10.1002/rmv.2273] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 12/11/2022]
Abstract
The coronavirus disease 2019 (Covid-19) pandemic has had devastating effects on public health worldwide, but the deployment of vaccines for Covid-19 protection has helped control the spread of SARS Coronavirus 2 (SARS-CoV-2) infection where they are available. The common side effects reported following Covid-19 vaccination were mostly self-restricted local reactions that resolved quickly. Nevertheless, rare vaccine-induced immune thrombotic thrombocytopenia (VITT) cases have been reported in some people being vaccinated against Covid-19. This review summarizes the thromboembolic events after Covid-19 vaccination and discusses its molecular mechanism, incidence rate, clinical manifestations and differential diagnosis. Then, a step-by-step algorithm for diagnosing such events, along with a management plan, are presented. In conclusion, considering the likeliness of acquiring severe SARS-CoV-2 infection and its subsequent morbidity and mortality, the benefits of vaccination outweigh its risks. Hence, if not already initiated, all governments should begin an effective and fast public vaccination plan to overcome this pandemic.
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Affiliation(s)
- Zeinab Mohseni Afshar
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Arefeh Babazadeh
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Alireza Janbakhsh
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mandana Afsharian
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Kiarash Saleki
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran.,USERN Office, Babol University of Medical Sciences, Babol, Iran
| | - Mohammad Barary
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran.,USERN Office, Babol University of Medical Sciences, Babol, Iran
| | - Soheil Ebrahimpour
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
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39
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Douxfils J, Favresse J, Dogné JM, Lecompte T, Susen S, Cordonnier C, Lebreton A, Gosselin R, Sié P, Pernod G, Gruel Y, Nguyen P, Vayne C, Mullier F. Hypotheses behind the very rare cases of thrombosis with thrombocytopenia syndrome after SARS-CoV-2 vaccination. Thromb Res 2021; 203:163-171. [PMID: 34029848 PMCID: PMC8123522 DOI: 10.1016/j.thromres.2021.05.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 01/17/2023]
Abstract
As of 4 April 2021, a total of 169 cases of cerebral venous sinus thrombosis (CVST) and 53 cases of splanchnic vein thrombosis were reported to EudraVigilance among around 34 million people vaccinated in the European Economic Area and United Kingdom with COVID-19 Vaccine AstraZeneca, a chimpanzee adenoviral vector (ChAdOx1) encoding the spike protein antigen of the SARS-CoV-2 virus. The first report of the European Medicines Agency gathering data on 20 million people vaccinated with Vaxzevria® in the UK and the EEA concluded that the number of post-vaccination cases with thromboembolic events as a whole reported to EudraVigilance in relation to the number of people vaccinated was lower than the estimated rate of such events in the general population. However, the EMA's Pharmacovigilance Risk Assessment Committee concluded that unusual thromboses with low blood platelets should be listed as very rare side effects of Vaxzevria®, pointing to a possible link. The same issue was identified with the COVID-19 Vaccine Janssen (Ad26.COV2.S). Currently, there is still a sharp contrast between the clinical or experimental data reported in the literature on COVID-19 and the scarcity of data on the unusual thrombotic events observed after the vaccination with these vaccines. Different hypotheses might support these observations and should trigger further in vitro and ex vivo investigations. Specialized studies were needed to fully understand the potential relationship between vaccination and possible risk factors in order to implement risk minimization strategies.
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Affiliation(s)
- Jonathan Douxfils
- University of Namur, Department of Pharmacy, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, Namur, Belgium; QUALIblood s.a., Namur, Belgium.
| | - Julien Favresse
- University of Namur, Department of Pharmacy, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, Namur, Belgium; Clinique Saint-Luc Bouge, Department of Laboratory Medicine, Bouge, Belgium
| | - Jean-Michel Dogné
- University of Namur, Department of Pharmacy, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, Namur, Belgium
| | - Thomas Lecompte
- Départements de Médecine, Hôpitaux Universitaires de Genève, service d'angiologie et d'hémostase et Faculté de Médecine, Geneva Platelet Group (GpG), Université de Genève, Geneva, Switzerland
| | - Sophie Susen
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, F-59000 Lille, France
| | - Charlotte Cordonnier
- Univ Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
| | - Aurélien Lebreton
- Service d'hématologie biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Robert Gosselin
- University of California, Davis Health System, Thrombosis and Hemostasis Center, Sacramento, United States
| | - Pierre Sié
- University Paul Sabatier, CHU of Toulouse, Laboratory of Hematology, F-31069 Toulouse, France
| | - Gilles Pernod
- CHU Grenoble Alpes, Department of Vascular Medicine, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble, France
| | - Yves Gruel
- University of Tours, EA7501 GICC, CHRU de Tours, Department of Haemostasis, Tours, France
| | | | - Caroline Vayne
- University of Tours, EA7501 GICC, CHRU de Tours, Department of Haemostasis, Tours, France
| | - François Mullier
- CHU UCL Namur, Université catholique de Louvain, Hematology Laboratory, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, Yvoir, Belgium
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40
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Warkentin TE, Greinacher A. Spontaneous HIT syndrome: Knee replacement, infection, and parallels with vaccine-induced immune thrombotic thrombocytopenia. Thromb Res 2021; 204:40-51. [PMID: 34144250 DOI: 10.1016/j.thromres.2021.05.018] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 12/21/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is characterized clinically by thrombocytopenia, hypercoagulability, and increased thrombosis risk, and serologically by platelet-activating anti-platelet factor 4 (PF4)/heparin antibodies. Heparin-"induced" acknowledges that HIT is usually triggered by a proximate immunizing exposure to heparin. However, certain non-heparin medications (pentosan polysulfate, hypersulfated chondroitin sulfate, fondaparinux) can trigger "HIT". Further, naturally-occurring polyanions (bacterial lipopolysaccharide, DNA/RNA) can interact with PF4 to recapitulate HIT antigens. Indeed, immunologic presensitization to naturally-occurring polyanions could explain why HIT more closely resembles a secondary, rather than a primary, immune response. In 2008 it was first reported that a HIT-mimicking disorder can occur without any preceding exposure to heparin or polyanionic medications. Termed "spontaneous HIT syndrome", two subtypes are recognized: (a) surgical (post-orthopedic, especially post-total knee arthroplasty, and (b) medical (usually post-infectious). Recently, COVID-19 adenoviral vector vaccination has been associated with a thrombotic thrombocytopenic disorder associated with positive PF4-dependent enzyme-immunoassays and serum-induced platelet activation that is maximal when PF4 is added. Vaccine-induced immune thrombotic thrombocytopenia (VITT) features unusual thromboses (cerebral venous thrombosis, splanchnic vein thrombosis) similar to those seen in spontaneous HIT syndrome. The emerging concept is that classic HIT reflects platelet-activating anti-PF4/heparin antibodies whereas spontaneous HIT syndrome and other atypical "autoimmune HIT" presentations (delayed-onset HIT, persisting HIT, heparin "flush" HIT) reflect heparin-independent platelet-activating anti-PF4 antibodies-although the precise relationships between PF4 epitope targets and the clinical syndromes remain to be determined. Treatment of spontaneous HIT syndrome includes non-heparin anticoagulation (direct oral Xa inhibitors favored over direct thrombin inhibitors) and high-dose immunoglobulin.
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Hamilton Regional Laboratory Medicine Program (Transfusion Medicine), Hamilton, Ontario, Canada; Service of Benign Hematology, Hamilton Health Sciences (Hamilton General Hospital), Canada.
| | - Andreas Greinacher
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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Greinacher A, Thiele T, Warkentin TE, Weisser K, Kyrle PA, Eichinger S. Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination. N Engl J Med 2021; 384:2092-2101. [PMID: 33835769 PMCID: PMC8095372 DOI: 10.1056/nejmoa2104840] [Citation(s) in RCA: 1547] [Impact Index Per Article: 515.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Several cases of unusual thrombotic events and thrombocytopenia have developed after vaccination with the recombinant adenoviral vector encoding the spike protein antigen of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (ChAdOx1 nCov-19, AstraZeneca). More data were needed on the pathogenesis of this unusual clotting disorder. METHODS We assessed the clinical and laboratory features of 11 patients in Germany and Austria in whom thrombosis or thrombocytopenia had developed after vaccination with ChAdOx1 nCov-19. We used a standard enzyme-linked immunosorbent assay to detect platelet factor 4 (PF4)-heparin antibodies and a modified (PF4-enhanced) platelet-activation test to detect platelet-activating antibodies under various reaction conditions. Included in this testing were samples from patients who had blood samples referred for investigation of vaccine-associated thrombotic events, with 28 testing positive on a screening PF4-heparin immunoassay. RESULTS Of the 11 original patients, 9 were women, with a median age of 36 years (range, 22 to 49). Beginning 5 to 16 days after vaccination, the patients presented with one or more thrombotic events, with the exception of 1 patient, who presented with fatal intracranial hemorrhage. Of the patients with one or more thrombotic events, 9 had cerebral venous thrombosis, 3 had splanchnic-vein thrombosis, 3 had pulmonary embolism, and 4 had other thromboses; of these patients, 6 died. Five patients had disseminated intravascular coagulation. None of the patients had received heparin before symptom onset. All 28 patients who tested positive for antibodies against PF4-heparin tested positive on the platelet-activation assay in the presence of PF4 independent of heparin. Platelet activation was inhibited by high levels of heparin, Fc receptor-blocking monoclonal antibody, and immune globulin (10 mg per milliliter). Additional studies with PF4 or PF4-heparin affinity purified antibodies in 2 patients confirmed PF4-dependent platelet activation. CONCLUSIONS Vaccination with ChAdOx1 nCov-19 can result in the rare development of immune thrombotic thrombocytopenia mediated by platelet-activating antibodies against PF4, which clinically mimics autoimmune heparin-induced thrombocytopenia. (Funded by the German Research Foundation.).
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Affiliation(s)
- Andreas Greinacher
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Thomas Thiele
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Theodore E Warkentin
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Karin Weisser
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Paul A Kyrle
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Sabine Eichinger
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
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Thrombotic Thrombocytopenia after COVID-19 Vaccination: In Search of the Underlying Mechanism. Vaccines (Basel) 2021; 9:vaccines9060559. [PMID: 34071883 PMCID: PMC8227748 DOI: 10.3390/vaccines9060559] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/13/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023] Open
Abstract
The rollout of COVID-19 vaccines brings hope for successful pandemic mitigation and getting the transmission of SARS-CoV-2 under control. The vaccines authorized in Europe displayed a good safety profile in the clinical trials. However, during their post-authorization use, unusual thrombotic events associated with thrombocytopenia have rarely been reported for vector vaccines. This led to the temporary suspension of the AZD1222 vaccine (Oxford/AstraZeneca) in various European countries and the Ad26.COV2 vaccine (Janssen/Johnson&Johnson) in the United States, with regulatory bodies launching investigations into potential causal associations. The thromboembolic reactions were also rarely reported after mRNA vaccines. The exact cause of these adverse effects remains to be elucidated. The present paper outlines the hypotheses on the mechanisms behind the very rare thrombotic thrombocytopenia reported after the COVID-19 vaccination, along with currently existing evidence and future research prospects. The following are discussed: (i) the role of antibodies against platelet factor 4 (PF4), (ii) the direct interaction between adenoviral vector and platelets, (iii) the cross-reactivity of antibodies against SARS-CoV-2 spike protein with PF4, (iv) cross-reactivity of anti-adenovirus antibodies and PF4, (v) interaction between spike protein and platelets, (vi) the platelet expression of spike protein and subsequent immune response, and (vii) the platelet expression of other adenoviral proteins and subsequent reactions. It is also plausible that thrombotic thrombocytopenia after the COVID-19 vaccine is multifactorial. The elucidation of the causes of these adverse events is pivotal in taking precautionary measures and managing vaccine hesitancy. It needs to be stressed, however, that the reported cases are currently sporadic and that the benefits of COVID-19 vaccines vastly outweigh their potential risks.
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A case of vaccine-induced immune thrombotic thrombocytopenia with massive artero-venous thrombosis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2021; 19:343-346. [PMID: 34059191 DOI: 10.2450/2021.0131-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 05/03/2021] [Indexed: 12/17/2022]
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Abstract
The number of people affected by COVID-19 is staggering and countries are rushing and competing to vaccinate their populations. However, there has been a concern about the association between COVID-19 vector-based vaccines and thrombosis. The proposed mechanism by which a COVID-19 vector-based vaccine can cause thrombosis is called vaccine-induced immune thrombotic thrombocytopenia (VITT). This commentary will provide an easy sketch of VITT as well as presentation of thrombosis after COVID-19 vaccines and proposed treatment.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Mohamed A Hendaus
- Department of Pediatrics, Sidra Medicine, Doha, Qatar.,Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Fatima A Jomha
- School of Pharmacy, Lebanese International University, Lebanon
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Hammond SM, Aartsma‐Rus A, Alves S, Borgos SE, Buijsen RAM, Collin RWJ, Covello G, Denti MA, Desviat LR, Echevarría L, Foged C, Gaina G, Garanto A, Goyenvalle AT, Guzowska M, Holodnuka I, Jones DR, Krause S, Lehto T, Montolio M, Van Roon‐Mom W, Arechavala‐Gomeza V. Delivery of oligonucleotide-based therapeutics: challenges and opportunities. EMBO Mol Med 2021; 13:e13243. [PMID: 33821570 PMCID: PMC8033518 DOI: 10.15252/emmm.202013243] [Citation(s) in RCA: 161] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 12/12/2022] Open
Abstract
Nucleic acid-based therapeutics that regulate gene expression have been developed towards clinical use at a steady pace for several decades, but in recent years the field has been accelerating. To date, there are 11 marketed products based on antisense oligonucleotides, aptamers and small interfering RNAs, and many others are in the pipeline for both academia and industry. A major technology trigger for this development has been progress in oligonucleotide chemistry to improve the drug properties and reduce cost of goods, but the main hurdle for the application to a wider range of disorders is delivery to target tissues. The adoption of delivery technologies, such as conjugates or nanoparticles, has been a game changer for many therapeutic indications, but many others are still awaiting their eureka moment. Here, we cover the variety of methods developed to deliver nucleic acid-based therapeutics across biological barriers and the model systems used to test them. We discuss important safety considerations and regulatory requirements for synthetic oligonucleotide chemistries and the hurdles for translating laboratory breakthroughs to the clinic. Recent advances in the delivery of nucleic acid-based therapeutics and in the development of model systems, as well as safety considerations and regulatory requirements for synthetic oligonucleotide chemistries are discussed in this review on oligonucleotide-based therapeutics.
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Affiliation(s)
| | | | - Sandra Alves
- Department of Human Genetics, Research and Development UnitNational Health Institute Doutor Ricardo JorgePortoPortugal
| | - Sven E Borgos
- Department of Biotechnology and NanomedicineSINTEF ASTrondheimNorway
| | - Ronald A M Buijsen
- Department of Human GeneticsLeiden University Medical CenterLeidenThe Netherlands
| | - Rob W J Collin
- Department of Human Genetics and Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CenterNijmegenThe Netherlands
| | - Giuseppina Covello
- Department of BiologyUniversity of PadovaPadovaItaly
- Department of Cellular, Computational and Integrative Biology ‐ CIBIOUniversity of TrentoTrentoItaly
| | - Michela A Denti
- Department of Cellular, Computational and Integrative Biology ‐ CIBIOUniversity of TrentoTrentoItaly
| | - Lourdes R Desviat
- Centro de Biología Molecular Severo Ochoa UAM‐CSICCIBERER, IdiPazUniversidad Autónoma de MadridMadridSpain
| | | | - Camilla Foged
- Department of PharmacyFaculty of Health and Medical SciencesUniversity of CopenhagenCopenhagen ØDenmark
| | - Gisela Gaina
- Victor Babes National Institute of PathologyBucharestRomania
- Department of Biochemistry and Molecular BiologyUniversity of BucharestBucharestRomania
| | - Alejandro Garanto
- Department of Human Genetics and Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CenterNijmegenThe Netherlands
- Department of PediatricsRadboud University Medical CenterNijmegenThe Netherlands
| | | | - Magdalena Guzowska
- Department of Physiological SciencesFaculty of Veterinary MedicineWarsaw University of Life Sciences – SGGWWarsawPoland
| | - Irina Holodnuka
- Institute of Microbiology and VirologyRiga Stradins UniversityRigaLatvia
| | | | - Sabine Krause
- Department of NeurologyFriedrich‐Baur‐InstituteLudwig‐Maximilians‐University of MunichMunichGermany
| | - Taavi Lehto
- Institute of TechnologyUniversity of TartuTartuEstonia
- Division of Biomolecular and Cellular MedicineDepartment of Laboratory MedicineKarolinska InstitutetHuddingeSweden
| | - Marisol Montolio
- Duchenne Parent Project EspañaMadridSpain
- Department of Cell Biology, Fisiology and ImmunologyFaculty of BiologyUniversity of BarcelonaBarcelonaSpain
| | - Willeke Van Roon‐Mom
- Department of Human GeneticsLeiden University Medical CenterLeidenThe Netherlands
| | - Virginia Arechavala‐Gomeza
- Neuromuscular Disorders GroupBiocruces Bizkaia Health Research InstituteBarakaldoSpain
- Ikerbasque, Basque Foundation for ScienceBilbaoSpain
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Alam W. COVID-19 vaccine-induced immune thrombotic thrombocytopenia: A review of the potential mechanisms and proposed management. Sci Prog 2021; 104:368504211025927. [PMID: 34120531 PMCID: PMC10358704 DOI: 10.1177/00368504211025927] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
With over 600 million coronavirus (COVID-19) vaccine doses administered globally, adverse events are constantly monitored. Recently however, reports of thrombosis and thrombocytopenia following vaccination with the ChAdOx1 nCoV-19 vaccine have emerged. This paper aims to review the available literature and guidelines pertaining to vaccine-induced immune thrombotic thrombocytopenia (VITT) and the proposed guidelines, while offering a potential approach that unifies the available evidence. While the risk of VITT remains extremely low and the benefits outweigh the risks, experimental studies are needed to clarify the pathophysiology behind VITT and possibly decrease the risk of thrombosis and other adverse events occurring. However, treatment should not be delayed in suspected cases, and IV immunoglobulin and non-heparin anticoagulation should be initiated.
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Affiliation(s)
- Walid Alam
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Hvas AM, Favaloro EJ, Hellfritzsch M. Heparin-induced thrombocytopenia: pathophysiology, diagnosis and treatment. Expert Rev Hematol 2021; 14:335-346. [PMID: 33736552 DOI: 10.1080/17474086.2021.1905512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Immune-mediated heparin-induced thrombocytopenia (HIT) is an infrequent complication following heparin exposure but with potentially fatal outcome due to thrombotic complications. Prompt suspension of heparin is necessary if HIT is suspected, followed by initiation of non-heparin anticoagulant therapy.Areas covered: In this review, the pathophysiology and challenges in diagnosing HIT are elucidated. Current and emerging treatment options are discussed with special focus on parenteral thrombin inhibitors (argatroban, bivalirudin), parenteral factor Xa inhibitors (danaparoid, fondaparinux) and direct oral anticoagulants (DOACs [rivaroxaban, apixaban, dabigatran]) including dosing strategies for DOACs. The database PubMed was employed without time boundaries.Expert opinion: Only argatroban holds regulatory approval for HIT treatment in both U.S. and Europe. This treatment is, however, challenged by the need for close monitoring and high costs. Fondaparinux has been increasingly used for off-label treatment and during recent years, evidence for the use of DOACs has emerged. Preliminary results from observational studies hold promise for future use of DOACs in the acute and subacute phase of HIT. However, so far, the use of DOACs in acute HIT should be reserved for clinically stable patients without severe thrombotic complications. Importantly, both fondaparinux and DOAC use is contraindicated in severe renal insufficiency.
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Affiliation(s)
- Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University. Address: Palle Juul-Jensens Boulevard 99, Aarhus N, Denmark
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, Australia
| | - Maja Hellfritzsch
- Department of Cardiology, Herning Regional Hospital, Herning, Denmark
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Emami N, Ferdousi R. AptaNet as a deep learning approach for aptamer-protein interaction prediction. Sci Rep 2021; 11:6074. [PMID: 33727685 PMCID: PMC7971039 DOI: 10.1038/s41598-021-85629-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 03/03/2021] [Indexed: 02/08/2023] Open
Abstract
Aptamers are short oligonucleotides (DNA/RNA) or peptide molecules that can selectively bind to their specific targets with high specificity and affinity. As a powerful new class of amino acid ligands, aptamers have high potentials in biosensing, therapeutic, and diagnostic fields. Here, we present AptaNet-a new deep neural network-to predict the aptamer-protein interaction pairs by integrating features derived from both aptamers and the target proteins. Aptamers were encoded by using two different strategies, including k-mer and reverse complement k-mer frequency. Amino acid composition (AAC) and pseudo amino acid composition (PseAAC) were applied to represent target information using 24 physicochemical and conformational properties of the proteins. To handle the imbalance problem in the data, we applied a neighborhood cleaning algorithm. The predictor was constructed based on a deep neural network, and optimal features were selected using the random forest algorithm. As a result, 99.79% accuracy was achieved for the training dataset, and 91.38% accuracy was obtained for the testing dataset. AptaNet achieved high performance on our constructed aptamer-protein benchmark dataset. The results indicate that AptaNet can help identify novel aptamer-protein interacting pairs and build more-efficient insights into the relationship between aptamers and proteins. Our benchmark dataset and the source codes for AptaNet are available in: https://github.com/nedaemami/AptaNet .
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Affiliation(s)
- Neda Emami
- Department of Health Information Technology, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Ferdousi
- Department of Health Information Technology, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.
- Research Center for Pharmaceutical Nanotechnology, Biomedicine Institute, Tabriz University of Medical Sciences, Tabriz, Iran.
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Heparin-Induced Thrombocytopenia: A Review of New Concepts in Pathogenesis, Diagnosis, and Management. J Clin Med 2021; 10:jcm10040683. [PMID: 33578859 PMCID: PMC7916628 DOI: 10.3390/jcm10040683] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 12/17/2022] Open
Abstract
Knowledge on heparin-induced thrombocytopenia keeps increasing. Recent progress on diagnosis and management as well as several discoveries concerning its pathogenesis have been made. However, many aspects of heparin-induced thrombocytopenia remain partly unknown, and exact application of these new insights still need to be addressed. This article reviews the main new concepts in pathogenesis, diagnosis, and management of heparin-induced thrombocytopenia.
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Gaunt ER, Mabbott NA. The clinical correlates of vaccine-induced immune thrombotic thrombocytopenia after immunisation with adenovirus vector-based SARS-CoV-2 vaccines. IMMUNOTHERAPY ADVANCES 2021; 1:ltab019. [PMID: 34557868 PMCID: PMC8385946 DOI: 10.1093/immadv/ltab019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/04/2021] [Accepted: 08/16/2021] [Indexed: 12/13/2022] Open
Abstract
We are at a critical stage in the COVID-19 pandemic where vaccinations are being rolled out globally, in a race against time to get ahead of the SARS-CoV-2 coronavirus and the emergence of more highly transmissible variants. A range of vaccines have been created and received either emergency approval or full licensure. To attain the upper hand, maximum vaccine synthesis, deployment, and uptake as rapidly as possible is essential. However, vaccine uptake, particularly in younger adults is dropping, at least in part fuelled by reports of rare complications associated with specific vaccines. This review considers how vaccination with adenovirus vector-based vaccines against the SARS-CoV-2 coronavirus might cause rare cases of thrombosis and thrombocytopenia in some recipients. A thorough understanding of the underlying cellular and molecular mechanisms that mediate this syndrome may help to identify methods to prevent these very rare, but serious side effects. This will also help facilitate the identification of those at highest risk from these outcomes, so that we can work towards a stratified approach to vaccine deployment to mitigate these risks.
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Affiliation(s)
- Eleanor R Gaunt
- The Roslin Institute & Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian EH25 9RG, UK
| | - Neil A Mabbott
- The Roslin Institute & Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian EH25 9RG, UK
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