Comparison of vaccine-induced thrombotic events between ChAdOx1 nCoV-19 and Ad26.COV.2.S vaccines

Central nervous system manifestations following vaccination against COVID-19

Coronavirus disease 2019 (COVID-19) vaccination has become the most effective countermeasure in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. However, vaccination is associated with side effects. This narrative review focuses on central nervous system (CNS) manifestations following COVID-19 vaccination and provides a summary of the potential underlying mechanisms and methods of diagnosis and management of the vaccination-related CNS manifestations. Headache, myalgia, optic neuritis, seizure, multiple sclerosis, acute disseminated encephalomyelitis and encephalitis, delirium, acute transverse myelitis, and stroke have been reported after COVID-19 vaccination. Constant headache and myalgia are common manifestations that may necessitate further clinical investigation for stroke. To limit consequences, it is imperative to follow standard treatment protocols for each neurological disorder following COVID-19 vaccination. Immunosuppressive medication can be helpful in the treatment of seizures following vaccination since the immune response is involved in their etiology. Clinicians should be aware of the manifestations after COVID-19 vaccination to respond promptly and effectively. Clinical guidelines for the management of CNS manifestations following COVID-19 vaccination are in high demand and would be useful in each new SARS-CoV-2 variant pandemic.

Cerebral venous thrombosis in patients with autoimmune disease, hematonosis or coronavirus disease 2019: Many familiar faces and some strangers

BACKGROUND

Cerebral venous thrombosis, a rare stroke, is characterized by neurological dysfunction caused by bleeding and/or infarction resulting from venous sinus thrombosis, the so-called venous stroke. Current guidelines recommend anticoagulants as first-line therapy in the treatment of venous stroke. With complicated causes of cerebral venous thrombosis, treatment is difficult, especially when combined with autoimmune diseases, blood diseases, and even COVID-19.

AIMS

This review summarizes the pathophysiological mechanisms, epidemiology, diagnosis, treatment, and clinical prognosis of cerebral venous thrombosis combined with autoimmune diseases, blood diseases, or infectious diseases such as COVID-19.

CONCLUSION

A systematic understanding of particular risk factors that should not be neglected when unconventional cerebral venous thrombosis occurs and for a scientific understanding of pathophysiological mechanisms, clinical diagnosis, and treatment, thus contributing to knowledge on special types of venous stroke.

Research progress of NF-κB signaling pathway and thrombosis

Venous thromboembolism is a very common and costly health problem. Deep-vein thrombosis (DVT) can cause permanent damage to the venous system and lead to swelling, ulceration, gangrene, and other symptoms in the affected limb. In addition, more than half of the embolus of pulmonary embolism comes from venous thrombosis, which is the most serious cause of death, second only to ischemic heart disease and stroke patients. It can be seen that deep-vein thrombosis has become a serious disease affecting human health. In recent years, with the deepening of research, inflammatory response is considered to be an important pathway to trigger venous thromboembolism, in which the transcription factor NF-κB is the central medium of inflammation, and the NF-κB signaling pathway can regulate the pro-inflammatory and coagulation response. Thus, to explore the mechanism and make use of it may provide new solutions for the prevention and treatment of thrombosis.

Vaccine-Induced Immune Thrombocytopenia and Thrombosis (VITT)-Insights from Clinical Cases, In Vitro Studies and Murine Models

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.

Two Cases of Venous Thromboembolism Shortly After Adenovirus-Based COVID-19 Vaccination

As the coronavirus disease 2019 (COVID-19) global pandemic continues, multiple vaccines have been developed to decrease infection rate and number of deaths. Vaccine administration is especially important as new COVID-19 variants emerge. While the number of severe thromboembolic events reported after adenovirus-based vaccination has gained attention, there is little information regarding the presentation and management of post-vaccination venous thromboembolism (VTE). Here, we present two cases of VTE after the Janssen vaccine administration. In the first case, a 98-year-old African American female with hypertension developed bilateral lower extremity edema that evolved into unilateral lower extremity edema 20-35 days following the Janssen vaccine administration. She was found to have an extensive unilateral proximal femoral deep vein thrombosis (DVT) 35 days after the vaccination. In the second case, a 64-year-old African American female developed ecchymosis and unilateral edema six days after the Janssen vaccine administration. She was found to have proximal superficial vein thrombosis two days later. In both cases, laboratory data, including platelets and anti-heparin antibodies were within normal limits. Thus, VTE may be an adverse effect of the Janssen vaccine or any adenovirus-based vaccine, but further surveillance and investigation to elucidate this association are necessary. We advise practitioners to have a high index of suspicion for thrombosis after Janssen vaccine administration, regardless of the presence of thrombocytopenia, and avoidance of heparin products until heparin antibody results return.

[Neurological complications after covid-19 vaccination]

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

A systematic review of current status and challenges of vaccinating children against SARS-CoV-2

The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has inflicted immense damage to countries, economies and societies worldwide. Authorized COVID-19 vaccines based on different platforms have been widely inoculated in adults, showing up to 100% immunogenicity with significant efficacy in preventing SARS-CoV-2 infections and the occurrence of severe COVID-19. It has also greatly slowed the evolution of SARS-CoV-2 variants, as shown in clinical trials and real-world evidence. However, the total dosage of COVID-19 vaccines for children is much smaller than that for adults due to limitations from parental concern of vaccine safety, presenting a potential obstacle in ending the COVID-19 pandemic. SARS-CoV-2 not only increases the risk of severe multisystem inflammatory syndrome (MIS-C) in children, but also negatively affects children's psychology and academics, indirectly hindering the maintenance and progress of normal social order. Therefore, this article examines the clinical manifestations of children infected with SARS-CoV-2, the status of vaccination against COVID-19 in children, vaccination-related adverse events, and the unique immune mechanisms of children. In particular, the necessity and challenges of vaccinating children against SARS-CoV-2 were highlighted from the perspectives of society and family. In summary, parental hesitancy is unnecessary as adverse events after COVID-19 vaccination have been proven to be infrequent, comprise of mild symptoms, and have a good prognosis.

COVID-19 Infection Risk Following Elective Arthroplasty and Surgical Complications in COVID-19 Vaccinated Patients: A Multicenter Comparative Cohort Study

Background

We aimed to determine symptomatic Coronavirus disease 2019 (COVID-19) rates within 1 month of elective arthroplasty for vaccinated individuals and to determine whether vaccination guarantees protection against COVID-19 after arthroplasty (primary outcome). In addition, the 90-day surgical complications were compared to those of an unvaccinated group (secondary outcome).

Methods

A prospective cohort study was conducted on elective joint arthroplasty patients at 3 tertiary hospitals in 2 major cities (Tehran and Isfahan) in our country (Iran). The outcomes of the COVID-19-vaccinated group were assessed between October 2021 and March 2022. Ninety-day surgical complications were compared with a historical cohort of unvaccinated patients treated earlier in the pandemic (April 2020-March 2021).

Results

The study included 1717 consecutive patients: 962 vaccinated and 755 unvaccinated. In the vaccinated group, 38 patients (3.9%) contracted COVID-19, 4 (10.5%) were hospitalized again, and none required intensive care unit admission. The multivariate logistic regression analysis revealed that COVID-19-positive cases are more likely to be female (odds ratio [OR] = 12.5), to have visitors to their home (OR = 4.7), and to stay longer in the hospital (OR = 1.2) than COVID-19-negative cases. Compared to unvaccinated patients, the postoperative COVID-19 rate was not significantly different (3.9% vs 2.4%, P = .07). The incidence of surgical complications was similar between the 2 groups (P > .05).

Conclusions

The vaccination does not provide a guarantee that a patient will not contract COVID-19 following their arthroplasty surgery, especially in a region with a high rate of COVID-19. We believe reasonable perioperative COVID-19 precautions may be warranted even in vaccinated patients.

Sports Imaging of COVID-19: A Multi-Organ System Review of Indications and Imaging Findings

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified in December 2019 in Wuhan, China. Although coronavirus disease-19 (COVID-19) affects every population group, the sports community and athletes require special consideration of the effects on cardiovascular, musculoskeletal, neurologic, and respiratory systems. A comprehensive understanding of imaging indications, findings, and features of COVID-19 supports appropriate imaging utilization and effective patient management and treatment.

PURPOSE

To review the spectrum of sports imaging in COVID-19 infection, organ system manifestations, vaccine effects, and complications in recreational and competitive athletes.

STUDY DESIGN

Narrative review.

LEVEL OF EVIDENCE

Levels 4 and 5.

METHODS

Based on a PubMed database search, studies describing the imaging findings of COVID-19 infection, organ system manifestations, vaccine effects, and complications in recreational and competitive athletes were included.

RESULTS

On March 11, 2020, World Health Organization officially declared COVID-19 a global pandemic. As of May 9, 2022, more than 515 million confirmed cases of COVID-19 were reported globally. While the multisystem effects of COVID-19 are incompletely understood, the role of imaging in diagnosing, monitoring, and prognosticating active disease, long-term effects, and complications is evolving. In the respiratory system, imaging plays an important role in diagnosing, characterizing, and monitoring pulmonary COVID-19 infections, barotrauma, and COVID-19-associated chronic pulmonary opacities and fibrotic-like lung changes. Ultrasonography, computed tomography, and magnetic resonance imaging aid in the timely diagnosis of ischemic, embolic, and thrombotic peripheral and central cardiovascular events, including deep venous thrombosis, pulmonary embolism, myocarditis, and stroke. COVID-19-associated musculoskeletal and peripheral nervous system manifestations include rhabdomyolysis and myonecrosis, plexus and peripheral neuropathies, Guillain-Barré syndrome, and shoulder injury related to vaccine administration.

CONCLUSIONS

In athletes, COVID-19 infections and associated effects on cardiovascular, musculoskeletal, neurologic, and respiratory systems require special consideration. With the increasing understanding of the multisystem effects of COVID-19, the role of imaging in diagnosing, monitoring, and prognosticating active disease, long-term effects, and complications is evolving. A comprehensive understanding of imaging indications, COVID-19 imaging features, and organ system effects aids in appropriate imaging utilization and effective patient management and treatments.

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

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

Rates, types, and associated factors of acute adverse effects after the first dose of ChAdOx1 nCoV-19 vaccine administration in Thailand

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Acute adverse effects (AAEs) occurred in 65% of vaccinated participants

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Most adverse reactions were mild, including arm pain and low-grade fever

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AAEs were associated with younger age, female sex, anxiousness, and allergic disease

Objectives

Effective vaccines are prioritized to curtail the transmission and burden of coronavirus disease 2019. Nevertheless, monitoring the safety of vaccines is crucial. As Thailand began the ChAdOx1 nCoV-19 vaccination, our study examined the acute adverse effects and associated factors after the first dose of vaccination.

Methods

A mobile self-report questionnaire was employed to assess the rates and types of different side-effects within 3 days of the first dose of ChAdOx1 nCoV-19 vaccine administration. The risk factors associated with these side-effects were analyzed.

Results

In total, 774 participants were included in the survey, with a mean (± standard deviation) age of 49.5 (± 17.2) years. The majority (57.8%) were females, and 59.1% were anxious before the vaccination. Side-effects after the vaccination were a common occurrence (65.2%), but most (42.6%) were mild. Side-effects were significantly associated (odds ratio [95% confidence interval]) with younger age (4.32 [2.26–8.23]; p < 0.001; age < 30 years vs ≥ 60 years), female sex (1.66 [1.19–2.30], p = 0.003), anxiousness (2.10 [1.06–4.13]; p = 0.033; moderate–severe anxiousness vs none), and allergic disease (2.60 [1.07–6.31]; p = 0.035).

Conclusions

After the ChAdOx1 nCoV-19 vaccination, most acute adverse effects were mild and often noted among participants with younger age, female sex, anxiousness, and allergic disease.

Stroke Associated with COVID-19 Vaccines

Objectives

Development of safe and effective vaccines against coronavirus disease 2019 (COVID-19) remains the cornerstone of controlling this pandemic. However, there are increasing reports of various types of stroke including ischemic stroke, and hemorrhagic stroke, as well as cerebral venous sinus thrombosis (CVST) after COVID-19 vaccination. This paper aims to review reports of stroke associated with COVID-19 vaccines and provide a coherent clinical picture of this condition.

Materials and methods

A literature review was performed with a focus on data from recent studies.

Results

Most of such patients are women under 60 years of age and who had received ChAdOx1 nCoV-19 vaccine. Most studies reported CVST with or without secondary ischemic or hemorrhagic stroke, and some with Vaccine-induced Thrombotic Thrombocytopenia (VITT). The most common clinical symptom of CVST seen after COVID-19 vaccination was headache. The clinical course of CVST after COVID-19 vaccination may be more severe than CVST not associated with COVID vaccination. Management of CVST following COVID-19 vaccination is challenging and may differ from the standard treatment of CVST. Low molecular weight heparin is commonly used in the treatment of CVST; however, it may worsen outcomes in CVST associated with VITT. Furthermore, administration of intravenous immunoglobulin and high-dose glucocorticoids have been recommended with various success rates.

Conclusion

These contradictory observations are a source of confusion in clinical decision-making and warrant further study and development of clinical guidelines. Clinicians should be aware of clinical presentation, diagnosis, and management of stroke associated with COVID-19 vaccination.

Outcomes of patients with thromboembolic events following coronavirus disease 2019 AstraZeneca vaccination: a systematic review and meta-analysis

AstraZeneca coronavirus disease 2019 (COVID-19) vaccinations have recently been implicated in thromboembolism formations. Our aim was to investigate the outcomes of patients with thromboembolic events following the AstraZeneca vaccine (ChAdOx1 nCoV-19, AZD1222). A literature search was performed from December 2019 to September 2021. Eligible studies must report participants older than 18 years vaccinated with AstraZeneca and outcomes of thromboembolic events. Pooled mean or proportion were analyzed using a random-effects model. A total of 45 unique studies (number of patients = 144, 64.6% women, mean age 21-68 years) were included. The most common presenting adverse events were headache (12.1%), intracerebral hemorrhage (7.5%), and hemiparesis (7%). The most common thromboembolic adverse events were cerebral venous sinus thrombosis (38.5%) and deep vein thrombosis/pulmonary embolism (21.1%). The most common radiologic finding were intracerebral hemorrhage and cerebral venous thrombosis. Laboratory findings included thrombocytopenia (75%) and hypofibrinogenemia (41%). On admission, 64 patients tested positive for PF4-Heparin ELISA assay (80%). Seventy-four patients were hospitalized with 22 being admitted to the ICU. A total of 78 patients recovered while 39 patients died. This meta-analysis presents evidence to suggest vaccine-induced immune thrombotic thrombocytopenia (VITT) following AstraZeneca vaccine. Clinical practice must, therefore, account for the possibility of VITT and subsequent embolic events in certain individuals' postvaccination with adenovirus-based COVID-19 vaccines. Serum anti-PF4 suggests diagnostic value for VITT and could subsequently inform treatment choices in such instances.

Post COVID-19 vaccine deaths - Singapore's early experience

Singapore has been using mRNA vaccines developed by Pfizer-BioNTech and Moderna as part of the nation's COVID vaccination program since 30 December 2020. From 1 February 2021-30 June 2021, a total of 34 deaths that occurred within 72 h of the deceased receiving their COVID-19 vaccination were referred to the Forensic Medicine Division of the Health Sciences Authority of Singapore. Autopsies, histological sampling and ancillary investigations consisting of total tryptase level, Immunoglobulin E (IgE), and C-reactive Protein (CRP), were performed on 29 of these cases. Our study has shown no definite causative relationship between the mRNA vaccination and deaths of individuals who died within 72 h after receiving the vaccination, in particular with regards to anaphylactic reactions, myocarditis and pericarditis, and thrombotic complications. Further studies may consider increasing the incident time frame from 72 h to seven days post-vaccination or longer to include any potential delayed presentation of adverse effects.

Reported Adverse Effects and Attitudes among Arab Populations Following COVID-19 Vaccination: A Large-Scale Multinational Study Implementing Machine Learning Tools in Predicting Post-Vaccination Adverse Effects Based on Predisposing Factors

Background: The unprecedented global spread of coronavirus disease 2019 (COVID-19) has imposed huge challenges on the healthcare facilities, and impacted every aspect of life. This has led to the development of several vaccines against COVID-19 within one year. This study aimed to assess the attitudes and the side effects among Arab communities after receiving a COVID-19 vaccine and use of machine learning (ML) tools to predict post-vaccination side effects based on predisposing factors. Methods: An online-based multinational survey was carried out via social media platforms from 14 June to 31 August 2021, targeting individuals who received at least one dose of a COVID-19 vaccine from 22 Arab countries. Descriptive statistics, correlation, and chi-square tests were used to analyze the data. Moreover, extensive ML tools were utilized to predict 30 post vaccination adverse effects and their severity based on 15 predisposing factors. The importance of distinct predisposing factors in predicting particular side effects was determined using global feature importance employing gradient boost as AutoML. Results: A total of 10,064 participants from 19 Arab countries were included in this study. Around 56% were female and 59% were aged from 20 to 39 years old. A high rate of vaccine hesitancy (51%) was reported among participants. Almost 88% of the participants were vaccinated with one of three COVID-19 vaccines, including Pfizer-BioNTech (52.8%), AstraZeneca (20.7%), and Sinopharm (14.2%). About 72% of participants experienced post-vaccination side effects. This study reports statistically significant associations (p < 0.01) between various predisposing factors and post-vaccinations side effects. In terms of predicting post-vaccination side effects, gradient boost, random forest, and XGBoost outperformed other ML methods. The most important predisposing factors for predicting certain side effects (i.e., tiredness, fever, headache, injection site pain and swelling, myalgia, and sleepiness and laziness) were revealed to be the number of doses, gender, type of vaccine, age, and hesitancy to receive a COVID-19 vaccine. Conclusions: The reported side effects following COVID-19 vaccination among Arab populations are usually non-life-threatening; flu-like symptoms and injection site pain. Certain predisposing factors have greater weight and importance as input data in predicting post-vaccination side effects. Based on the most significant input data, ML can also be used to predict these side effects; people with certain predicted side effects may require additional medical attention, or possibly hospitalization.

The role of anti-platelet factor 4 antibodies and platelet activation tests in patients with vaccine-induced immune thrombotic thrombocytopenia: Comparison of the manifestation, laboratory diagnosis, and management in clinical scenario

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel human pathogen causing coronavirus disease 2019 (COVID-19). Rare cases of COVID-19 vaccine-induced immune thrombotic thrombocytopenia (VITT) after the ChAdOx1 nCoV-19 (AstraZeneca) vaccination have been reported. We performed a test for anti-heparin/ platelet factor 4 (PF4) antibodies and functional assay using flow cytometry.

Method

A healthy woman presented to the emergency department with chest pain, headache, and abdominal pain after the first vaccination with AstraZeneca. Polymerase chain reaction (PCR) test for SARS-CoV-2 was negative. Chest computed tomography (CT) showed pulmonary artery embolism and brain magnetic resonance imaging (MRI) revealed cerebral sinus-venous thrombosis. Abdominal CT demonstrated the thrombosis with occlusion in her right hepatic vein. Laboratory studies revealed decreased platelet counts, and high D-dimer level. Finally, laboratory results indicated high PF4 antibodies level high and a positive platelet activation test, confirming the diagnosis of VITT.

Results

Treatments including intravenous immunoglobulin, methylprednisolone and direct oral anticoagulant were administered. The results of a follow-up platelet count and D-dimer were normal. In addition, the titer of PF4 antibodies (optical density: 0.425; normal ≤ 0.4, enzyme-linked immunosorbent assay) fell. After a 3-month follow-up, her general condition improved gradually.

Conclusions

The use of COVID-19 vaccines to prevent SARS-CoV-2 infections and complications is considered the most practicable policy for controlling the COVID-19 pandemic and is being forcefully pursued in the global area. Appropriate laboratory diagnosis facilitates the accurate and rapid diagnosis. Early recognizing and appropriate strategies for VITT are required and can provide these patients with more favorable patient outcomes. This report also elected to make comparisons of clinical manifestation, laboratory diagnosis, and management in patients with VITT.

Adenovirus vector-based vaccine for infectious diseases

Replication-incompetent adenovirus (Ad) vectors have been widely used as gene delivery vehicles in both gene therapy studies and basic studies for gene function analysis due to their highly advantageous properties, which include high transduction efficiencies, relatively large capacities for transgenes, and high titer production. In addition, Ad vectors induce moderate levels of innate immunity and have relatively high thermostability, making them very attractive as potential vaccine vectors. Accordingly, it is anticipated that Ad vectors will be used in vaccines for the prevention of infectious diseases, including Ebola virus disease and acquired immune deficiency syndrome (AIDS). Much attention is currently focused on the potential use of an Ad vector vaccine for coronavirus disease 2019 (COVID-19). In this review, we describe the basic properties of an Ad vector, Ad vector-induced innate immunity and immune responses to Ad vector-produced transgene products. Development of novel Ad vectors which can overcome the drawbacks of conventional Ad vector vaccines and clinical application of Ad vector vaccines to several infectious diseases are also discussed.

EGF domain peptide of Developmentally regulated endothelial locus1 facilitates gene expression of extracellularly applied plasmid DNA

Background

The successful development of messenger RNA vaccines for SARS-CoV-2 opened up venues for clinical nucleotide-based vaccinations. For development of DNA vaccines, we tested whether the EGF domain peptide of Developmentally regulated endothelial locus1 (E3 peptide) enhances uptake of extracellularly applied plasmid DNA.

Methods

DNA plasmid encoding lacZ or GFP was applied with a conditioned culture medium containing E3 peptide to cell lines in vitro or mouse soleus muscles in vivo, respectively. After 48 h incubation, gene expression was examined by β-galactosidase (β-gal) assay and fluorescent microscope, respectively.

Results

Application of E3 peptide-containing medium to cultured cell lines induced intense β-gal activity in a dose-dependent manner. Intra-gastrocnemius injection of E3 peptide-containing medium to mouse soleus muscle succeeded in the induction of GFP fluorescence in many cells around the injection site.

Conclusions

The administration of E3 peptide facilitates transmembrane uptake of extracellular DNA plasmid which induces sufficient extrinsic gene expression.

Post COVID-19 Vaccination-Associated Neurological Complications

PURPOSE

Neurological sequelae after COVID-19 vaccination are rare. We investigated the possible pathogenesis behind the development of neurological complications within a short period after Saudi residents received a COVID-19 vaccine.

PATIENTS AND METHODS

We evaluated 18 patients who recently received a COVID-19 vaccine (Comirnaty and Vaxzevria vaccines) and presented with neurological complications to the Saudi German Hospitals in Jeddah, Saudi Arabia. Neurologists assessed the patients' clinical presentation, radiological investigations, and laboratory findings.

RESULTS

Three patients who received the first dose of the Vaxzevria vaccine experienced severe cerebral venous thrombosis, two of them were complicated by intracranial hemorrhage. Their laboratory investigations showed very high d-dimers and severe thrombocytopenia, which have been linked to higher mortality and poor outcome. Ischemic stroke occurred in eight cases (44.4%) with a predominance in older male patients. Three patients presented with seizures, two had optic neuritis. Guillain-Barré syndrome (GBS) and Miller Fisher syndrome (MFS) occurred in two male patients following vaccination with Comirnaty.

CONCLUSION

Neurological complications after COVID-19 vaccinations are very rare, and only a few cases have been reported worldwide. The shared pathophysiological basis between COVID-19 viral infection and COVID-19 vaccines stands behind the very rare neurological complications resulting from the hypercoagulable state triggered by the general inflammatory condition. We suspect some differences in the pathogenesis of ischemic stroke caused by COVID-19 infection and COVID-19 vaccines, which render COVID-19 vaccine-associated ischemic stroke more responsive to treatment. To date, no definitive association between the vaccine and GBS has been proven by any strong evidence, but it has recently been added as a very rare side effect of the Janssen COVID-19 vaccine. No possible links of Miller Fisher syndrome to COVID-19 vaccines have been reported before the one reported in this study.

New-onset autoimmune phenomena post COVID-19 vaccination

Coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented setback for global economy and health. Vaccination is one of the most effective intervention to substantially reduce severe disease and death due to SARS-CoV-2 infection. Vaccination programs are being rolled out globally, but most of these vaccines have been approved without extensive studies on their side effects and efficacy. Recently, new-onset autoimmune phenomena after COVID-19 vaccination have been reported increasingly (e.g., immune thrombotic thrombocytopenia, autoimmune liver diseases, Guillain-Barré syndrome, IgA nephropathy, rheumatoid arthritis and systemic lupus erythematosus, etc.). Molecular mimicry, the production of particular autoantibodies and the role of certain vaccine adjuvants seem to be substantial contributors to autoimmune phenomena. However, whether the association between COVID-19 vaccine and autoimmune manifestations is coincidental or causal remains to be elucidated. Here, we summarize the emerging evidence about autoimmune manifestations occurring in response to certain COVID-19 vaccines. Although information pertaining to the risk of autoimmune disease as a consequence of vaccination is controversial, we merely propose our current understanding of autoimmune manifestations associated with COVID-19 vaccine. In fact, we do not aim to disavow the overwhelming benefits of mass COVID-19 vaccination in preventing COVID-19 morbidity and mortality. These reports could help guide clinical assessment and management of autoimmune manifestations after COVID-19 vaccination.

Clinical significance of hepatosplenic thrombosis in vaccine-induced immune thrombotic thrombocytopenia after ChAdOx1 nCoV-19 vaccination

BACKGROUND

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare, serious complication after adenoviral COVID-19 vaccine administration that can involve various organ systems. We aimed to investigate the clinical significance of hepatosplenic thrombosis in patients with VITT.

METHODS

We searched PubMed ePubs, Scopus, Embase, and Web of Science databases for studies published until April 28, 2021 involving patients with VITT after ChAdOx1 nCoV-19 vaccination. Demographic and clinical characteristics including laboratory measurements were collected and compared.

RESULTS

Four case series and three case reports involving 48 cases of VITT were included. Hepatosplenic thrombosis was present in eight cases (17%). Patients with hepatosplenic thrombosis had lower platelet counts (13,000 vs. 29,500/μL, p=0.016) and higher D-dimer levels (140.0 vs. 57.3 times upper limit of normal range, p=0.028). Multiple-site thrombosis was also associated with hepatosplenic thrombosis (88% vs. 15%, p<0.001).

CONCLUSIONS

This is the first study comparing clinical profiles of patients with VITT according to the presence of hepatosplenic thrombosis. Patients with hepatosplenic thrombosis had more severe presentations with lower platelet counts, higher D-dimer levels, and higher rate of multiple-site thromboses. Further studies with larger sample sizes are required to establish definitive evidence regarding the significance of hepatosplenic thrombosis in VITT.

Association of cerebral venous thrombosis with recent COVID-19 vaccination: case-crossover study using ascertainment through neuroimaging in Scotland

BACKGROUND

To investigate the association of primary acute cerebral venous thrombosis (CVT) with COVID-19 vaccination through complete ascertainment of all diagnosed CVT in the population of Scotland.

METHODS

Case-crossover study comparing cases of CVT recently exposed to vaccination (1-14 days after vaccination) with cases less recently exposed. Cases in Scotland from 1 December 2020 were ascertained through neuroimaging studies up to 17 May 2021 and diagnostic coding of hospital discharges up to 28 April 2021, linked to national vaccination records. The main outcome measure was primary acute CVT.

RESULTS

Of 50 primary acute CVT cases, 29 were ascertained only from neuroimaging studies, 2 were ascertained only from hospital discharges, and 19 were ascertained from both sources. Of these 50 cases, 14 had received the Astra-Zeneca ChAdOx1 vaccine and 3 the Pfizer BNT162b2 vaccine. The incidence of CVT per million doses in the first 14 days after vaccination was 2.2 (95% credible interval 0.9 to 4.1) for ChAdOx1 and 1 (95% credible interval 0.1 to 2.9) for BNT162b2. The rate ratio for CVT associated with exposure to ChAdOx1 in the first 14 days compared with exposure 15-84 days after vaccination was 3.2 (95% credible interval 1.1 to 9.5).

CONCLUSIONS

These findings support a causal association between CVT and the AstraZeneca vaccine. The absolute risk of post-vaccination CVT in this population-wide study in Scotland was lower than has been reported for populations in Scandinavia and Germany; the explanation for this is not clear.

Platelet Activation Mechanisms and Consequences of Immune Thrombocytopenia

Autoimmune disorders are often associated with low platelet count or thrombocytopenia. In immune-induced thrombocytopenia (IIT), a common mechanism is increased platelet activity, which can have an increased risk of thrombosis. In addition, or alternatively, auto-antibodies suppress platelet formation or augment platelet clearance. Effects of the auto-antibodies are linked to the unique structural and functional characteristics of platelets. Conversely, prior platelet activation may contribute to the innate and adaptive immune responses. Extensive interplay between platelets, coagulation and complement activation processes may aggravate the pathology. Here, we present an overview of the reported molecular causes and consequences of IIT in the most common forms of autoimmune disorders. These include idiopathic thrombocytopenic purpura (ITP), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), drug-induced thrombocytopenia (DITP), heparin-induced thrombocytopenia (HIT), COVID-19 vaccine-induced thrombosis with thrombocytopenia (VITT), thrombotic thrombocytopenia purpura (TTP), and hemolysis, the elevated liver enzymes and low platelet (HELLP) syndrome. We focus on the platelet receptors that bind auto-antibodies, the immune complexes, damage-associated molecular patterns (DAMPs) and complement factors. In addition, we review how circulating platelets serve as a reservoir of immunomodulatory molecules. By this update on the molecular mechanisms and the roles of platelets in the pathogenesis of autoimmune diseases, we highlight platelet-based pathways that can predispose for thrombocytopenia and are linked thrombotic or bleeding events.

Interactions of adenoviruses with platelets and coagulation and the vaccine-induced immune thrombotic thrombocytopenia syndrome

The COVID-19 pandemic has had a heavy impact on global health and economy and vaccination remains the primary way of controlling the infection. During the ongoing vaccination campaign some unexpected thrombotic events have emerged in subjects who had recently received the AstraZeneca (Vaxzevria) vaccine or the Johnson and Johnson (Janssen) vaccine, two adenovirus vector-based vaccines. Epidemiological studies confirm that the observed/expected ratio of these unusual thromboses is abnormally increased, especially in women in fertile age. The characteristics of this complication, with venous thromboses at unusual sites, most frequently in the cerebral vein sinuses but also in splanchnic vessels, often with multiple associated thromboses, thrombocytopenia, and sometimes disseminated intravascular coagulation, are unique and the time course and tumultuous evolution are suggestive of an acute immunological reaction. Indeed, plateletactivating anti-PF4 antibodies have been detected in a large proportion of the affected patients. Several data suggest that adenoviruses may interact with platelets, the endothelium and the blood coagulation system. Here we review interactions between adenoviral vectors and the hemostatic system that are of possible relevance in vaccine-associated thrombotic thrombocytopenia syndrome. We systematically analyze the clinical data on the reported thrombotic complications of adenovirus-based therapeutics and discuss all the current hypotheses on the mechanisms triggering this novel syndrome. Although, considering current evidence, the benefit of vaccination clearly outweighs the potential risks, it is of paramount importance to fully unravel the mechanisms leading to vaccineassociated thrombotic thrombocytopenia syndrome and to identify prognostic factors through further research.

An Insight into the Role of Postmortem Immunohistochemistry in the Comprehension of the Inflammatory Pathophysiology of COVID-19 Disease and Vaccine-Related Thrombotic Adverse Events: A Narrative Review

On 11 March 2020, the World Health Organization (WHO) declared a pandemic due to the spread of COVID-19 from Wuhan, China, causing high mortality rates all over the world. The related disease, which mainly affects the lungs, is responsible for the onset of Diffuse Alveolar Damage (DAD) and a hypercoagulability state, frequently leading to Severe Acute Respiratory Syndrome (SARS) and multiorgan failure, particularly in old and severe-critically ill patients. In order to find effective therapeutic strategies, many efforts have been made aiming to shed light on the pathophysiology of COVID-19 disease. Moreover, following the late advent of vaccination campaigns, the need for the comprehension of the pathophysiology of the fatal, although rare, thrombotic adverse events has become mandatory as well. The achievement of such purposes needs a multidisciplinary approach, depending on a correct interpretation of clinical, biochemical, biomolecular, and forensic findings. In this scenario, autopsies have helped in defining, on both gross and histologic examinations, the main changes to which the affected organs undergo and the role in assessing whether a patient is dead “from” or “with” COVID-19, not to mention whether the existence of a causal link exists between vaccination and thrombotic adverse events. In the present work, we explored the role of postmortem immunohistochemistry, and the increasingly used ancillary technique, in helping to understand the mechanism underlying the pathophysiology of both COVID-19 disease and COVID-19 vaccine-related adverse and rare effects.

Cerebral Venous Thrombosis Developing after COVID-19 Vaccination: VITT, VATT, TTS, and More

Despite the huge efforts globally underway for preventing or limiting the spread of severe acute respiratory coronavirus disease 2 (SARS-CoV-2), the coronavirus disease 2019 (COVID-19) pandemic outbreak appears still virtually unstoppable. As for many other infectious diseases, COVID-19 vaccination has now become crucial for limiting viral spread, especially for averting hospitalizations, need for intensive care, and fatal outcome. Nonetheless, as for other vaccines, COVID-19 vaccination is not completely free from side effects. Among the adverse events that have been reported after receiving COVID-19 vaccination, special emphasis has been given to an unexpected number of thrombocytopenic episodes with or without thrombotic complications, especially in recipients of adenovirus-based COVID-19 vaccines. Along with a specific clinical presentation, encompassing "atypical" thrombosis (especially cerebral venous [sinus] thrombosis, CVT) more prevalent in young female subjects, this new syndrome called vaccine-induced thrombocytopenia and thrombosis (VITT) is characterized by, and thereby diagnosed for, the presence of three paradigmatic laboratory abnormalities, i.e., low platelet count (<150 × 10⁹/L), elevated plasma D-dimer levels (>0.5 mg/L), accompanied by a positive test for anti-PF4 (platelet factor 4) antibodies assayed with ELISA (enzyme-linked immunosorbent assay) techniques. Timely identification of these important abnormalities by both clinicians and laboratory professional is essential for early diagnosis and management of VITT, since the outcome of this condition may be fatal in half or even more of effected patients with severe disease. Therefore, this narrative review aims to review here the epidemiology, pathogenesis, clinical, and laboratory characteristics of VITT and other COVID-19 vaccine-associated thrombocytopenias.

Predictors of mortality in thrombotic thrombocytopenia after adenoviral COVID-19 vaccination: the FAPIC score

AIMS

The clinical manifestation and outcomes of thrombosis with thrombocytopenia syndrome (TTS) after adenoviral COVID-19 vaccine administration are largely unknown due to the rare nature of the disease. We aimed to analyse the clinical presentation, treatment modalities, outcomes, and prognostic factors of adenoviral TTS, as well as identify predictors for mortality.

METHODS AND RESULTS

PubMed, Scopus, Embase, and Web of Science databases were searched and the resulting articles were reviewed. A total of 6 case series and 13 case reports (64 patients) of TTS after ChAdOx1 nCoV-19 vaccination were included. We performed a pooled analysis and developed a novel scoring system to predict mortality. The overall mortality of TTS after ChAdOx1 nCoV-19 vaccination was 35.9% (23/64). In our analysis, age ≤60 years, platelet count <25 × 103/µL, fibrinogen <150 mg/dL, the presence of intracerebral haemorrhage (ICH), and the presence of cerebral venous thrombosis (CVT) were significantly associated with death and were selected as predictors for mortality (1 point each). We named this novel scoring system FAPIC (fibrinogen, age, platelet count, ICH, and CVT), and the C-statistic for the FAPIC score was 0.837 (95% CI 0.732-0.942). Expected mortality increased with each point increase in the FAPIC score, at 2.08, 6.66, 19.31, 44.54, 72.94, and 90.05% with FAPIC scores 0, 1, 2, 3, 4, and 5, respectively. The FAPIC scoring model was internally validated through cross-validation and bootstrapping, then externally validated on a panel of TTS patients after Ad26.COV2.S administration.

CONCLUSIONS

Fibrinogen levels, age, platelet count, and the presence of ICH and CVT were significantly associated with mortality in patients with TTS, and the FAPIC score comprising these risk factors could predict mortality. The FAPIC score could be used in the clinical setting to recognize TTS patients at high risk of adverse outcomes and provide early intensive interventions including intravenous immunoglobulins and non-heparin anticoagulants.

Successful treatment of thromboses of major arteries after ChAdOx1 nCov-19 vaccination

The ChAdOx1 nCoV-19 adenoviral vector vaccine to prevent contracting Covid-19 caused by infection with SARS-CoV-2 has been associated with vaccine-induced immune thrombotic thrombocytopenia (VITT) primarily leading to venous thromboses. Here, we report two cases of major arterial occlusions after ChAdOx1 nCov-19 vaccination, comprising a 42-year-old woman with thrombotic occlusion of the left carotid artery, and a 62-year-old man with occlusion of distal aorta and iliac arteries. Both were successfully treated with intravenous immunoglobulins and non-heparin anticoagulant agents leading to a beneficial short-term outcome of 6 weeks in case 1 and four months in case 2.

Crossing the Rubicon: A fine line between waiting and vaccinating adolescents against COVID-19

Several countries with advanced adult COVID-19 immunisation programmes have already started vaccinating adolescents with an mRNA vaccine that recently received emergency use authorisation for 12–15 year-olds. The decision to vaccinate adolescents remains highly divisive among parents, clinicians, politicians and policy makers. There are very few downsides to immunising adolescents with a safe and effective COVID-19 vaccine because that would significantly reduce their risk of COVID-19 and all its complications. Based on current evidence, however, adolescents have a very low risk of severe or fatal COVID-19, even among those with comorbidities, or rare complications such as long COVID or Paediatric Multisystem Inflammatory Syndrome (PIMS-TS), a hyperinflammatory syndrome temporally associated with SARS-CoV-2. Additionally, currently authorised vaccines are very reactogenic and have limited post-marketing population-level safety data in adolescents and young adults, but these are emerging from countries that have forged ahead with vaccinating adolescents. Countries that have yet to make a recommendation can afford to wait until there is sufficient information to make informed decisions on the risk-benefits of vaccinating adolescents with current and future COVID-19 vaccines. Alternatives to two-dose vaccination in adolescents may include a single dose or a reduced dose schedule as is currently being trialled in younger children.