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Alhumaid S, Al Mutair A, Rabaan AA, ALShakhs FM, Choudhary OP, Yong SJ, Nainu F, Khan A, Muhammad J, Alhelal F, Al Khamees MH, Alsouaib HA, Al Majhad AS, Al-Tarfi HR, ALyasin AH, Alatiyyah YY, Alsultan AA, Alessa ME, Alessa ME, Alissa MA, Alsayegh EH, Alshakhs HN, Al Samaeel HA, AlShayeb RA, Alnami DA, Alhassan HA, Alabdullah AA, Alhmed AH, AlDera FH, Hajissa K, Al-Tawfiq JA, Al-Omari A. New-onset and relapsed liver diseases following COVID-19 vaccination: a systematic review. BMC Gastroenterol 2022; 22:433. [PMID: 36229799 PMCID: PMC9559550 DOI: 10.1186/s12876-022-02507-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Liver diseases post-COVID-19 vaccination is extremely rare but can occur. A growing body of evidence has indicated that portal vein thrombosis, autoimmune hepatitis, raised liver enzymes and liver injuries, etc., may be potential consequence of COVID-19 vaccines. OBJECTIVES To describe the results of a systematic review for new-onset and relapsed liver disease following COVID-19 vaccination. METHODS For this systematic review, we searched Proquest, Medline, Embase, PubMed, CINAHL, Wiley online library, Scopus and Nature through the Preferred Reporting Items for Systematic Reviews and Meta Analyses PRISMA guideline for studies on the incidence of new onset or relapsed liver diseases post-COVID-19 vaccination, published from December 1, 2020 to July 31, 2022, with English language restriction. RESULTS Two hundred seventy-five cases from one hundred and eighteen articles were included in the qualitative synthesis of this systematic review. Autoimmune hepatitis (138 cases) was the most frequent pathology observed post-COVID-19 vaccination, followed by portal vein thrombosis (52 cases), raised liver enzymes (26 cases) and liver injury (21 cases). Other cases include splanchnic vein thrombosis, acute cellular rejection of the liver, jaundice, hepatomegaly, acute hepatic failure and hepatic porphyria. Mortality was reported in any of the included cases for acute hepatic failure (n = 4, 50%), portal vein thrombosis (n = 25, 48.1%), splanchnic vein thrombosis (n = 6, 42.8%), jaundice (n = 1, 12.5%), raised liver enzymes (n = 2, 7.7%), and autoimmune hepatitis (n = 3, 2.2%). Most patients were easily treated without any serious complications, recovered and did not require long-term hepatic therapy. CONCLUSION Reported evidence of liver diseases post-COIVD-19 vaccination should not discourage vaccination against this worldwide pandemic. The number of reported cases is relatively very small in relation to the hundreds of millions of vaccinations that have occurred and the protective benefits offered by COVID-19 vaccination far outweigh the risks.
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Affiliation(s)
- Saad Alhumaid
- Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Ministry of Health, Rashdiah Street, P. O. Box 12944, Al-Ahsa, 31982, Saudi Arabia.
| | - Abbas Al Mutair
- Research Center, Almoosa Specialist Hospital, Al-Ahsa, Saudi Arabia.,College of Nursing, Princess Norah Bint Abdul Rahman University, Riyadh, Saudi Arabia.,School of Nursing, University of Wollongong, Wollongong, Australia
| | - Ali A Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia.,College of Medicine, Alfaisal University, Riyadh, 11533, Saudi Arabia.,Department of Public Health and Nutrition, The University of Haripur, Haripur, Pakistan
| | - Fatemah M ALShakhs
- Respiratory Therapy Department, Prince Saud Bin Jalawi Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Om Prakash Choudhary
- Department of Veterinary Anatomy and Histology, College of Veterinary Sciences and Animal Husbandry, Central Agricultural University (I), Selesih, Aizawl, Mizoram, 796015, India
| | - Shin Jie Yong
- Department of Biological Sciences, School of Medical and Life Sciences, Sunway University, Subang Jaya, Malaysia
| | - Firzan Nainu
- Department of Pharmacy, Faculty of Pharmacy, Hasanuddin University, Makassar, 90245, Indonesia
| | - Amjad Khan
- Department of Public Health and Nutrition, The University of Haripur, Haripur, Pakistan
| | - Javed Muhammad
- Department of Microbiology, The University of Haripur, Haripur, 22620, Khyber Pakhtunkhwa, Pakistan
| | - Fadil Alhelal
- Optometry Department, Dhahran Eye Specialist Hospital, Ministry of Health, Dhahran, Saudi Arabia
| | | | - Hussain Ahmed Alsouaib
- Medical Store Department, Maternity and Children Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Ahmed Salman Al Majhad
- Medical Store Department, Maternity and Children Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Hassan Redha Al-Tarfi
- Medical Store Department, Maternity and Children Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Ali Hussain ALyasin
- Medical Store Department, Maternity and Children Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | | | - Ali Ahmed Alsultan
- Medical Supply Store, Aloyoon General Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Mohammed Essa Alessa
- Inventory Control Unit, Aloyoon General Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Mustafa Essa Alessa
- Pharmacy Department, Aloyoon General Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Mohammed Ahmed Alissa
- Pharmacy Department, Aloyoon General Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Emad Hassan Alsayegh
- Pharmacy Department, Aloyoon General Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Hassan N Alshakhs
- Pharmacy Department, Aloyoon General Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | | | - Rugayah Ahmed AlShayeb
- Pharmacy Department, King Fahad Hofuf Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Dalal Ahmed Alnami
- Pharmacy Department, King Fahad Hofuf Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Hussain Ali Alhassan
- Pharmacy Department, Maternity and Children Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | | | - Ayat Hussain Alhmed
- Administration of Nursing Care, Maternity and Children Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Faisal Hussain AlDera
- General Surgery Department, King Fahad Hofuf Hospital, Ministry of Health, Al-Ahsa, Saudi Arabia
| | - Khalid Hajissa
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia
| | - Jaffar A Al-Tawfiq
- Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia.,Infectious Disease Division, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Infectious Disease Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Awad Al-Omari
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,Research Center, Dr. Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
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2
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Long-Term Outcomes after Vaccine-Induced Thrombotic Thrombocytopenia. Viruses 2022; 14:v14081702. [PMID: 36016324 PMCID: PMC9415056 DOI: 10.3390/v14081702] [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: 06/30/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023] Open
Abstract
Vaccine-induced thrombotic thrombocytopenia (VITT), or thrombosis with thrombocytopenia syndrome (TTS), is a rare but serious complication of adenovirus-based vaccines against severe respiratory syndrome coronavirus 2 (SARS-CoV-2). Observation of long-term outcomes is important to guide treatment of affected patients. This single-center consecutive cohort study included all patients diagnosed based on (1) vaccination 4 to 21 days before symptom onset, (2) signs or symptoms of venous or arterial thrombosis, (3) thrombocytopenia < 150/nL, (4) positive anti-platelet factor 4 (PF4) antibody, and (5) elevated D-Dimer > 4 times the upper limit of normal. Nine patients were enrolled. Acute management consisted of parenteral anticoagulants, corticosteroids, intravenous immunoglobulin (IVIG), and/or eculizumab. Eculizumab was successfully used in two patients with recurrent thromboembolic events after IVIG. Direct oral anticoagulants were given after hospital discharge. Median follow-up duration was 300 days (range 153 to 380). All patients survived the acute phase of the disease and were discharged from hospital. One patient died from long-term neurological sequelae of cerebral venous sinus thrombosis 335 days after diagnosis. Eight out of nine patients were alive at last follow-up, and seven had fully recovered. Anti-PF4 antibodies remained detectable for at least 12 weeks after diagnosis, and D-Dimer remained elevated in some patients despite oral anticoagulation. No recurrent thromboembolic events, other signs of VITT relapse, or bleeding complications occurred after discharge. In conclusion, VITT appears to be a highly prothrombotic condition. IVIG is not always successful, and eculizumab may be considered a rescue agent. Long-term management with direct oral anticoagulants appears to be safe and effective.
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García-Azorín D, Lázaro E, Ezpeleta D, Lecumberri R, Cámara RDL, Castellanos M, Martínez CI, Quiroga-González L, Rivas GE, Sancho-López A, Iglesias PR, Segovia E, Mejías C, Corominas DM. [Thrombosis with Thrombocytopenia Syndrome following adenovirus vector-based vaccines to prevent COVID-19: epidemiology and clinical presentation in Spain]. Neurologia 2022:S0213-4853(22)00067-6. [PMID: 35645442 PMCID: PMC9124923 DOI: 10.1016/j.nrl.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/24/2022] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND We describe the epidemiological and clinical characteristics of thrombosis with thrombocytopenia syndrome (TTS) cases reported in Spain. METHODS We included all venous or arterial thrombosis with thrombocytopenia following adenovirus vector-based vaccines (AstraZeneca or Janssen) to prevent COVID-19 disease between February 1st and September 26th, 2021. We describe the crude rate and the standardized morbidity ratio. We assessed the predictors of mortality. RESULTS Sixty-one cases were reported and 45 fulfilled eligibility criteria, 82% women. The crude TTS rate was 4/1,000,000 doses and 14-15/1,000,000 doses between 30-49 years. The number of observed cases of cerebral venous thrombosis was 6-18 higher than the expected in patients younger than 49 years. Symptoms started 10 (interquartile range (IQR): 7-14) days after vaccination. Eighty percent (95% confidence interval (CI): 65-90%) had thrombocytopenia at the time of the emergency department visit, and 65% (95% CI: 49-78%) had D-dimer >2000 ng/mL. Patients had multiple location thrombosis in 36% and fatal outcome in 24% cases. A platelet nadir <50,000 /μL (odds ratio (OR): 7.4; CI 95%: 1.2-47.5) and intracranial hemorrhage (OR: 7.9; IC95%: 1.3-47.0) were associated with fatal outcome. CONCLUSION TTS must be suspected in patients with symptoms 10 days after vaccination and thrombocytopenia and/or D-dimer increase.
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Affiliation(s)
- David García-Azorín
- Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Edurne Lázaro
- Pharm. División de Farmacoepidemiología y Farmacovigilancia. Departamento de Medicamentos de Uso Humano. Agencia Española de Medicamentos y Productos Sanitarios, España
| | - David Ezpeleta
- Servicio de Neurología. Hospital Universitario Quirónsalud Madrid. Pozuelo de Alarcón, Madrid, España
| | - Ramón Lecumberri
- Servicio de Hematología, Clínica Universidad de Navarra, Pamplona, España. CIBER-CV, Instituto de Salud Carlos III, Madrid, España
| | | | - Mar Castellanos
- Servicio de Neurología; Complejo Hospitalario Universitario/Instituto de Investigación Biomédica de Coruña. RD16/0019/0004 Instituto de Salud Carlos III, España
| | - Cristina Iñiguez Martínez
- Servicio de Neurología. Hospital Clínico Universitario Lozano Blesa, Zaragoza, España. Instituto de Investigación Sanitaria de Aragón (IIS Aragón), España
| | - Lara Quiroga-González
- Pharm. División de Farmacoepidemiología y Farmacovigilancia. Departamento de Medicamentos de Uso Humano. Agencia Española de Medicamentos y Productos Sanitarios, España
| | - Gabriela Elizondo Rivas
- Centro de Farmacovigilancia de Navarra. Departamento de Salud. Gobierno de Navarra, España. Presidenta del Comité Técnico del Sistema Español de Farmacovigilancia, España
| | - Aránzazu Sancho-López
- Servicio de Farmacología Clínica, Hospital Universitario Puerta de Hierro Majadahonda, España. Vocal SEFC, Grupo de Vacunas de FACME, España
| | - Pilar Rayón Iglesias
- División de Farmacoepidemiología y Farmacovigilancia. Departamento de Medicamentos de Uso Humano. Agencia Española de Medicamentos y Productos Sanitarios, España
| | - Eva Segovia
- División de Farmacoepidemiología y Farmacovigilancia. Departamento de Medicamentos de Uso Humano. Agencia Española de Medicamentos y Productos Sanitarios, España
| | - Consuelo Mejías
- División de Farmacoepidemiología y Farmacovigilancia. Departamento de Medicamentos de Uso Humano. Agencia Española de Medicamentos y Productos Sanitarios, España
| | - Dolores Montero Corominas
- División de Farmacoepidemiología y Farmacovigilancia. Departamento de Medicamentos de Uso Humano. Agencia Española de Medicamentos y Productos Sanitarios, España
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4
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Salih F, Kohler S, Schönborn L, Thiele T, Greinacher A, Endres M. Early recognition and treatment of pre-VITT syndrome after adenoviral vector-based SARS-CoV-2 vaccination may prevent from thrombotic complications: review of published cases and clinical pathway. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac036. [PMID: 35919343 PMCID: PMC9242075 DOI: 10.1093/ehjopen/oeac036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/30/2022] [Indexed: 11/26/2022]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare but highly morbid complication after adenoviral vector-based SARS-CoV-2 vaccination. The pre-VITT syndrome is defined as vaccine-induced immune thrombocytopenia without thrombosis typically presenting with new-onset headache. This review aims to identify at-risk patients before complications such as cerebral venous sinus thrombosis occur. We review previously published reports of 19 patients (median age 35 years, range 23-74; 16 females) who met the diagnostic criteria for a pre-VITT syndrome. Seven patients progressed to VITT, 12 patients did not. Patients who experienced VITT received delayed treatment. The median interval between the onset of headache and VITT-treatment (i.e. anticoagulation, immune globulins, or corticosteroids) was 5 days (range 1-8 days) compared with 2 days (0-5 days) in those without subsequent VITT (P = 0.033). The interval from onset of headache to anticoagulation was longer in patients with VITT (median 7 vs. 2 days; range 3-9 vs. 0-7 days; P = 0.01). Anticoagulation was safe in all patients with a pre-VITT syndrome as no haemorrhagic complications occurred after anticoagulation was started despite low platelets. The transient decline of platelet count after admission was significantly more pronounced in patients who progressed to VITT (median 67 vs. 0 × 103/µL; range 0-77 × 103/µL vs. 0-10 × 103/µL; P = 0.005). d-dimers did not differ between groups. Pre-VITT syndrome is a 'red flag' and allows to identify and preemptively treat patients at-risk of further progression to VITT. However, it must be distinguished from post-vaccination immune thrombocytopenia.
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Affiliation(s)
| | | | - Linda Schönborn
- Universitätsmedizin Greifswald, Institute of Immunology and Transfusion Medicine, Sauerbruch-Straße, 17489 Greifswald, Germany
| | - Thomas Thiele
- Universitätsmedizin Greifswald, Institute of Immunology and Transfusion Medicine, Sauerbruch-Straße, 17489 Greifswald, Germany
| | | | - Matthias Endres
- Corresponding author. Tel: +49 30 450 560101, Fax: +49 30 450 7560 932,
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5
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Ornelas-Aguirre JM, Gómez-Alcalá AV, Ramírez-Leyva DH. Increment of D-dimer Associated with Immune Thrombotic Thrombocytopenia in ChAdOx1 nCoV-19 (AstraZeneca-Oxford) Vaccinated Individuals: A Systematic Review. Arch Med Res 2022; 53:341-351. [DOI: 10.1016/j.arcmed.2022.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/02/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022]
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6
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Connors JM, Iba T. Vaccine-induced immune thrombotic thrombocytopenia and patients with cancer. Thromb Res 2022; 213 Suppl 1:S77-S83. [PMID: 36210565 PMCID: PMC9133965 DOI: 10.1016/j.thromres.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 01/17/2023]
Abstract
Vaccines to combat SARS-CoV-2 infection and the COVID-19 pandemic were quickly developed due to significant and combined efforts by the scientific community, government agencies, and private sector pharmaceutical and biotechnology companies. Following vaccine development, which took less than a year to accomplish, randomized placebo controlled clinical trials enrolled almost 100,000 people, demonstrating efficacy and no major safety signals. Vaccination programs were started, but shortly thereafter a small number of patients with a constellation of findings including thrombosis in unusual locations, thrombocytopenia, elevated D-dimer and often low fibrinogen led another intense and concentrated scientific effort to understand this syndrome. It was recognized that this occurred within a short time following administration of adenoviral vector SARS-CoV-2 vaccines. Critical to the rapid understanding of this syndrome was prompt communication among clinicians and scientists and exchange of knowledge. Now known as vaccine-induced immune thrombotic thrombocytopenia syndrome (VITT), progress has been made in understanding the pathophysiology of the syndrome, with the development of diagnostic criteria, and most importantly therapeutic strategies needed to effectively treat this rare complication of adenoviral vector vaccination. This review will focus on the current understanding of the pathophysiology of VITT, the findings that affected patients present with, and the rational for therapies, including for patients with cancer, as prompt recognition, diagnosis, and treatment of this syndrome has resulted in a dramatic decrease in associated mortality.
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Affiliation(s)
- Jean M. Connors
- Hematology Division, Brigham and Women's Hospital, Dana Farber Cancer institute, 75 Francis Street, Boston, MA 02115, United States of America,Corresponding author
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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7
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Schönborn L, Greinacher A. Longitudinal Aspects of VITT. Semin Hematol 2022; 59:108-114. [PMID: 35512899 PMCID: PMC8898788 DOI: 10.1053/j.seminhematol.2022.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/16/2022] [Accepted: 03/01/2022] [Indexed: 02/08/2023]
Abstract
In hundreds of patients worldwide, vaccination against COVID-19 with adenovirus vector vaccines (ChAdOx1 nCoV-19; Ad26.COV2.S) triggered platelet-activating anti-platelet factor 4 (PF4) antibodies inducing vaccine-induced immune thrombotic thrombocytopenia (VITT). In most VITT patients, platelet-activating anti-PF4-antibodies are transient and the disorder is discrete and non-recurring. However, in some patients platelet-activating antibodies persist, associated with recurrent thrombocytopenia and sometimes with relapse of thrombosis despite therapeutic-dose anticoagulation. Anti-PF4 IgG antibodies measured by enzyme-immunoassay (EIA) are usually detectable for longer than platelet-activating antibodies in functional assays, but duration of detectability is highly assay-dependent. As more than 1 vaccination dose against COVID-19 is required to achieve sufficient protection, at least 69 VITT patients have undergone subsequent vaccination with an mRNA vaccine, with no relevant subsequent increase in anti-PF4 antibody titers, thrombocytopenia, or thrombotic complications. Also, re-exposure to adenoviral vector-based vaccines in 5 VITT patients was not associated with adverse reactions. Although data are limited, vaccination against influenza also appears to be safe. SARS-CoV-2 infection reported in 1 patient with preceding VITT did not influence anti-PF4 antibody levels. We discuss how these temporal characteristics of VITT provide insights into pathogenesis.
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Affiliation(s)
| | - Andreas Greinacher
- Corresponding author. Andreas Greinacher, Professor, Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Sauerbruchstraße, Greifswald, D-17489, Germany. Tel.: +49 3834 865482; Fax: +49 3834 865489
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8
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Coagulopathy and Fibrinolytic Pathophysiology in COVID-19 and SARS-CoV-2 Vaccination. Int J Mol Sci 2022; 23:ijms23063338. [PMID: 35328761 PMCID: PMC8955234 DOI: 10.3390/ijms23063338] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/03/2022] [Accepted: 03/15/2022] [Indexed: 02/06/2023] Open
Abstract
Coronavirus Disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is frequently complicated by thrombosis. In some cases of severe COVID-19, fibrinolysis may be markedly enhanced within a few days, resulting in fatal bleeding. In the treatment of COVID-19, attention should be paid to both coagulation activation and fibrinolytic activation. Various thromboses are known to occur after vaccination with SARS-CoV-2 vaccines. Vaccine-induced immune thrombotic thrombocytopenia (VITT) can occur after adenovirus-vectored vaccination, and is characterized by the detection of anti-platelet factor 4 antibodies by enzyme-linked immunosorbent assay and thrombosis in unusual locations such as cerebral venous sinuses and visceral veins. Treatment comprises high-dose immunoglobulin, argatroban, and fondaparinux. Some VITT cases show marked decreases in fibrinogen and platelets and marked increases in D-dimer, suggesting the presence of enhanced-fibrinolytic-type disseminated intravascular coagulation with a high risk of bleeding. In the treatment of VITT, evaluation of both coagulation activation and fibrinolytic activation is important, adjusting treatments accordingly to improve outcomes.
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9
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Natural history of PF4 antibodies in vaccine induced immune thrombocytopenia and thrombosis. Blood 2022; 139:2553-2560. [PMID: 35263420 PMCID: PMC8912978 DOI: 10.1182/blood.2021014684] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/22/2022] [Indexed: 11/20/2022] Open
Abstract
The COVID-19 pandemic has resulted in the rapid development of a range of vaccines against SARS-CoV-2. Vaccine-induced immune thrombocytopenia and thrombosis (VITT) is a rare but life-threatening complication of primarily adenoviral-based vaccines associated with the presence of antibodies to a PF4/polyanion neoepitope and measured by using enzyme-linked immunosorbent assays. Presented are serial anti–PF4/polyanion antibody, platelet, and D-dimer measurements in a large cohort of patients and their relation to relapse. Overall, 51% of patients using the Stago assay had persistently positive anti–PF4/polyanion levels 100 days' postdiagnosis, whereas 94% of patients monitored by using the Immucor assay remain positive. The median duration of positivity of the PF4 assay is 87 days, with 72% of patients remaining positive after a median follow-up of 105 days. The use of plasma exchange seemed to reduce anti–PF4/polyanion levels and increase platelet counts in the acute setting more rapidly than other therapies. The rate of relapse in this study was 12.6%, with all relapsed cases exhibiting persistently positive PF4 antibodies and falling platelet counts. Only one patient had extension of their thrombosis. Overall, despite the persistence of PF4 antibodies in 72% of patients, the rate of relapse was low and did not seem to result in recrudescence of the aggressive clinical picture seen at index presentation. Monitoring of these patients in the UK cohort is ongoing and will aid in definition of the natural history of this novel condition.
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10
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Montague SJ, Smith CW, Lodwick CS, Stoneley C, Roberts M, Lowe GC, Lester WA, Watson SP, Nicolson PLR. Anti-platelet factor 4 immunoglobulin G levels in vaccine-induced immune thrombocytopenia and thrombosis: Persistent positivity through 7 months. Res Pract Thromb Haemost 2022; 6:e12707. [PMID: 35515079 PMCID: PMC9066380 DOI: 10.1002/rth2.12707] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/10/2022] [Accepted: 03/18/2022] [Indexed: 12/31/2022] Open
Abstract
Background Anti-platelet factor 4 (PF4) antibodies that activate platelets via FcγRIIA drive the pathophysiology of vaccine-induced immune thrombocytopenia and thrombosis (VITT). Evolution of these antibodies and their ability to activate platelets after initial treatment remains unknown. Objectives To assess how clinical and platelet parameters, anti-PF4 antibody levels, and patient serum reactivity changes during follow-up after VITT presentation. Methods We describe cases of seven discharged VITT patients that were followed from diagnosis up to 280 days (range 199-280) after vaccination. We measured anti-PF4 antibodies and PF4 levels in patient serum during follow-up and tested the ability of patient serum to activate healthy donor platelets and patient platelets over time. Results Anti-PF4 immunoglobulin G antibody levels are very high at diagnosis (0.9-2.6 OD) and remain relatively high (>1.0 OD) in all patients, except one treated with rituximab, at 7 months post vaccination. All patients were on direct oral anticoagulants throughout follow-up and no patients had recurrent thrombosis. Patients' platelets during follow-up have normal FcγRIIA levels and responsiveness to platelet agonists. Patient diagnostic serum strongly activated control platelets, either alone or with PF4. Most follow-up serum alone was weaker at stimulating donor and patient platelets. However, follow-up serum beyond 150 days still strongly activated platelets with PF4 addition in three patients. Patient serum PF4 levels were lower than controls at diagnosis but returned within normal range by day 50. Conclusions Explanations for reduced platelet activation during follow-up, despite similar total anti-PF4 antibody levels, remains unclear. Clinical implications of persistent anti-PF4 antibodies in VITT require further study.
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Affiliation(s)
- Samantha J Montague
- Institute of Cardiovascular Sciences College of Medical and Dental Sciences University of Birmingham Birmingham UK
| | - Christopher W Smith
- Institute of Cardiovascular Sciences College of Medical and Dental Sciences University of Birmingham Birmingham UK
| | - Clare S Lodwick
- Department of Haematology Worcester Acute Hospitals NHS Trust Worcester UK
| | - Charlotte Stoneley
- Department of Blood Sciences University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - Matthew Roberts
- Department of Blood Sciences University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - Gillian C Lowe
- Comprehensive Care Haemophilia Centre University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - William A Lester
- Comprehensive Care Haemophilia Centre University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - Steve P Watson
- Institute of Cardiovascular Sciences College of Medical and Dental Sciences University of Birmingham Birmingham UK
| | - Phillip L R Nicolson
- Institute of Cardiovascular Sciences College of Medical and Dental Sciences University of Birmingham Birmingham UK.,Comprehensive Care Haemophilia Centre University Hospitals Birmingham NHS Foundation Trust Birmingham UK
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11
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Comer SP, Le Chevillier A, Szklanna PB, Kelliher S, Saeed K, Cullen S, Edebiri O, O'Neill T, Stephens N, Weiss L, Murphy CA, Rajakumar S, Tierney A, Hughes C, Lennon Á, Moran N, Maguire PB, Ní Áinle F, Kevane B. Case Report: Hypergranular Platelets in Vaccine-Induced Thrombotic Thrombocytopenia After ChAdOx1 nCov-19 Vaccination. Front Cardiovasc Med 2022; 9:824601. [PMID: 35224056 PMCID: PMC8865139 DOI: 10.3389/fcvm.2022.824601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/17/2022] [Indexed: 01/14/2023] Open
Abstract
BackgroundVaccine-induced thrombotic thrombocytopenia (VITT) post SARS-CoV-2 vaccination is characterized by thrombocytopenia and severe thrombosis. Platelet function during patient recovery in the medium-/long-term has not been investigated fully. Here, we undertook a 3-month study, assessing the recovery of a VITT patient and assessing platelet morphology, granule content and dense-granule release at two distinct time points during recovery.Case PresentationA 61 year-old female was admitted to hospital 15 days post ChAdOx1 nCov-19 vaccination. Hematological parameters and peripheral blood smears were monitored over 3 months. Platelet morphology and granule populations were assessed using transmission electron microscopy (TEM) at two distinct time points during recovery, as was agonist-induced platelet dense-granule release. Upon admission, the patient had reduced platelet counts, increased D-dimer and high anti-PF4 antibodies with multiple sites of cerebral venous sinus thrombosis (CVST). Peripheral blood smears revealed the presence of large, hypergranular platelets. Following treatment, hematological parameters returned to normal ranges over the study period. Anti-PF4 antibodies remained persistently high up to 90 days post-admission. Two days after admission, VITT platelets contained more granules per-platelet when compared to day 72 and healthy platelets. Additionally, maximal ATP release (marker of dense-granule release) was increased on day 2 compared to day 72 and healthy control platelets.ConclusionThis study highlights a previously unreported observation of platelet hypergranularity in VITT which may contribute to the thrombotic risk associated with VITT. Optimal approaches to monitoring recovery from VITT over time remains to be determined but our findings may help inform therapeutic decisions relating to anticoagulation treatment in this novel pathology.
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Affiliation(s)
- Shane P. Comer
- Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Ana Le Chevillier
- Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Paulina B. Szklanna
- Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Sarah Kelliher
- Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Khalid Saeed
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Steven Cullen
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- Tallaght University Hospital, Dublin, Ireland
| | - Osasere Edebiri
- Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Tiina O'Neill
- Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
| | - Niamh Stephens
- Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
| | - Luisa Weiss
- Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Claire A. Murphy
- Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Saraswathi Rajakumar
- Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | | | - Conor Hughes
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Áine Lennon
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Niamh Moran
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Patricia B. Maguire
- Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
- UCD Institute for Discovery, University College Dublin, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Haematology, Rotunda Hospital, Dublin, Ireland
- *Correspondence: Fionnuala Ní Áinle
| | - Barry Kevane
- Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Barry Kevane
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Warkentin TE, Pai M. VIPIT versus VITT: what's in a name? Thromb Res 2021; 207:158-160. [PMID: 34757250 DOI: 10.1016/j.thromres.2021.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/08/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Menaka Pai
- Department of Pathology and Molecular Medicine, Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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13
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Thaler J, Ay C, Knoebl P. The path of uncovering a prothrombotic thrombocytopenic syndrome after viral vector-based COVID-19 vaccination: Where there is much light, the shadow is deep. Res Pract Thromb Haemost 2021; 5:e12609. [PMID: 34761155 PMCID: PMC8563919 DOI: 10.1002/rth2.12609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Johannes Thaler
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Paul Knoebl
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
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