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Lotti E, Gori AM, Berteotti M, Rogolino A, Cesari F, Poli D, Vannini F, Bertelli A, Giusti B, Marcucci R. Natural history of anti-PF 4 antibodies in patients with vaccine-induced immune thrombocytopenia and thrombosis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2024; 22:246-252. [PMID: 38315531 PMCID: PMC11073623 DOI: 10.2450/bloodtransfus.544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/12/2023] [Indexed: 02/07/2024]
Affiliation(s)
- Elena Lotti
- Atherothrombotic Disease Unit, Careggi University Hospital, Florence, Italy
| | - Anna M. Gori
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Martina Berteotti
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Angela Rogolino
- Atherothrombotic Disease Unit, Careggi University Hospital, Florence, Italy
| | - Francesca Cesari
- Atherothrombotic Disease Unit, Careggi University Hospital, Florence, Italy
| | - Daniela Poli
- Atherothrombotic Disease Unit, Careggi University Hospital, Florence, Italy
| | - Francesco Vannini
- Atherothrombotic Disease Unit, Careggi University Hospital, Florence, Italy
| | - Alessia Bertelli
- Atherothrombotic Disease Unit, Careggi University Hospital, Florence, Italy
| | - Betti Giusti
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Rossella Marcucci
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
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Clerici B, Pontisso E, Aloise C, Peroni B, Perricone R, Pisetta C, Scavone M, Birocchi S, Podda GM. Thrombosis and Bleeding in Patients with Vaccine-Induced Immune Thrombotic Thrombocytopenia: A Systematic Review of Published Cases. Thromb Haemost 2024; 124:423-431. [PMID: 38109906 DOI: 10.1055/s-0043-1777134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a highly prothrombotic reaction to COVID-19 (coronavirus disease 2019) adenoviral vector vaccines. Its distinct bleeding and thrombotic patterns compared with other platelet consumptive disorders remain unclear. METHODS We performed a systematic review of the literature (PubMed and Embase) up to July 31, 2022, including case reports and case series providing nonaggregate data of VITT patients. Accurate VITT diagnosis required fulfillment of the following criteria: (1) endorsement by the authors, (2) consistent vaccine type and timing, (3) presence of thrombocytopenia and thrombosis, (4) detection of anti-platelet factor 4 antibodies. Data are presented as frequencies with 95% confidence intervals (CIs) calculated with the exact binomial method. RESULTS We retrieved 143 eligible studies, describing 366 patients. Of 647 thrombotic events, 53% (95% CI: 49-56) were venous thromboses at unusual sites and 30% (95% CI: 27-34) were cerebral venous sinus thromboses (CVSTs). The ratio of venous-to-arterial events was 4.1. Thromboses in most sites were associated with at least another thrombotic event, with the exception of CVST and CNS arterial thrombosis (isolated in 49 and 39% of cases, respectively). Bleeding occurred in 36% (95% CI: 31-41) of patients; 68% (95% CI: 59-75) of bleeding events were intracranial hemorrhages (ICHs). Overall mortality was 24% (95% CI: 19-29), and 77% (95% CI: 58-90) in patients with isolated CVST complicated by ICH. CONCLUSION VITT displays a venous-to-arterial thrombosis ratio comparable to heparin-induced thrombocytopenia. However, VITT is characterized by a higher prevalence of CVST and ICH, which contribute to the increased bleeding frequency and mortality.
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Affiliation(s)
- Bianca Clerici
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Milano, Italy
| | - Eleonora Pontisso
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Milano, Italy
| | - Chiara Aloise
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Milano, Italy
| | - Benedetta Peroni
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Milano, Italy
| | - Rosaria Perricone
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Milano, Italy
| | - Chiara Pisetta
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Milano, Italy
| | - Mariangela Scavone
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Milano, Italy
| | - Simone Birocchi
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Milano, Italy
| | - Gian Marco Podda
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Milano, Italy
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Capecchi M, De Leo P, Abbattista M, Mancini I, Agosti P, Biganzoli M, Suffritti C, Ferrari B, Lecchi A, La Marca S, Padovan L, Scalambrino E, Clerici M, Tripodi A, Artoni A, Gualtierotti R, Peyvandi F. Risk of relapse after SARS-CoV-2 vaccine in the Milan cohort of thrombotic thrombocytopenic purpura patients. Haematologica 2023; 108:3152-3155. [PMID: 36951158 PMCID: PMC10620557 DOI: 10.3324/haematol.2022.282478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/14/2023] [Indexed: 03/24/2023] Open
Affiliation(s)
- Marco Capecchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; Clinica Moncucco, Division of Hematology, Lugano
| | - Pasqualina De Leo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Maria Abbattista
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Ilaria Mancini
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation and Fondazione Luigi Villa, Milan
| | - Pasquale Agosti
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation and Fondazione Luigi Villa, Milan
| | - Marina Biganzoli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Chiara Suffritti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Barbara Ferrari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Anna Lecchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Silvia La Marca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Lidia Padovan
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Erica Scalambrino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Marigrazia Clerici
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Armando Tripodi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Andrea Artoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Roberta Gualtierotti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation and Fondazione Luigi Villa, Milan
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation and Fondazione Luigi Villa, Milan.
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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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Schönborn L, Seck SE, Thiele T, Kaderali L, Hoffmann T, Hlinka A, Lindhoff-Last E, Völker U, Selleng K, Buoninfante A, Cavaleri M, Greinacher A. Long-term outcome in vaccine-induced immune thrombocytopenia and thrombosis. J Thromb Haemost 2023; 21:2519-2527. [PMID: 37394120 DOI: 10.1016/j.jtha.2023.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/13/2023] [Accepted: 06/17/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Rapid diagnosis and treatment has improved outcome of patients with vaccine-induced immune thrombocytopenia and thrombosis (VITT). However, after the acute episode, many questions on long-term management of VITT remained unanswered. OBJECTIVES To analyze, in patients with VITT, the long-term course of anti-platelet factor 4 (PF4) antibodies; clinical outcomes, including risk of recurrent thrombosis and/or thrombocytopenia; and the effects of new vaccinations. METHODS 71 patients with serologically confirmed VITT in Germany were enrolled into a prospective longitudinal study and followed for a mean of 79 weeks from March 2021 to January 2023. The course of anti-PF4 antibodies was analyzed by consecutive anti-PF4/heparin immunoglobulin G enzyme-linked immunosorbent assay and PF4-enhanced platelet activation assay. RESULTS Platelet-activating anti-PF4 antibodies became undetectable in 62 of 71 patients (87.3%; 95% CI, 77.6%-93.2%). In 6 patients (8.5%), platelet-activating anti-PF4 antibodies persisted for >18 months. Five of 71 patients (7.0%) showed recurrent episodes of thrombocytopenia and/or thrombosis; in 4 of them (80.0%), alternative explanations beside VITT were present. After further COVID-19 vaccination with a messenger RNA vaccine, no reactivation of platelet-activating anti-PF4 antibodies or new thrombosis was observed. No adverse events occurred in our patients subsequently vaccinated against influenza, tick-borne encephalitis, varicella, tetanus, diphtheria, pertussis, and polio. No new thrombosis occurred in the 24 patients (33.8%) who developed symptomatic SARS-CoV-2 infection following recovery from acute VITT. CONCLUSION Once the acute episode of VITT has passed, patients appear to be at low risk for recurrent thrombosis and/or thrombocytopenia.
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Affiliation(s)
- Linda Schönborn
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Sabrina E Seck
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institute of Transfusion Medicine, University Medicine Rostock, Rostock, Germany
| | - Lars Kaderali
- Institute of Bioinformatics, University Medicine Greifswald, Greifswald, Germany
| | - Till Hoffmann
- Institute for Transplantation Diagnostics and Cell Therapeutics, University Hospital Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Annalena Hlinka
- Institute for Transplantation Diagnostics and Cell Therapeutics, University Hospital Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Edelgard Lindhoff-Last
- Cardioangiology Center Bethanien Hospital, CCB Coagulation Center and CCB Coagulation Research Center, Frankfurt, Hessen, Germany
| | - Uwe Völker
- Interfaculty Institute of Genetics and Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Kathleen Selleng
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Alessandra Buoninfante
- Health Threats and Vaccines Strategy, European Medicines Agency, Amsterdam, The Netherlands
| | - Marco Cavaleri
- Health Threats and Vaccines Strategy, European Medicines Agency, Amsterdam, The Netherlands
| | - Andreas Greinacher
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany.
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Scholkmann F, May CA. COVID-19, post-acute COVID-19 syndrome (PACS, "long COVID") and post-COVID-19 vaccination syndrome (PCVS, "post-COVIDvac-syndrome"): Similarities and differences. Pathol Res Pract 2023; 246:154497. [PMID: 37192595 DOI: 10.1016/j.prp.2023.154497] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/25/2023] [Accepted: 05/01/2023] [Indexed: 05/18/2023]
Abstract
Worldwide there have been over 760 million confirmed coronavirus disease 2019 (COVID-19) cases, and over 13 billion COVID-19 vaccine doses have been administered as of April 2023, according to the World Health Organization. An infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to an acute disease, i.e. COVID-19, but also to a post-acute COVID-19 syndrome (PACS, "long COVID"). Currently, the side effects of COVID-19 vaccines are increasingly being noted and studied. Here, we summarise the currently available indications and discuss our conclusions that (i) these side effects have specific similarities and differences to acute COVID-19 and PACS, that (ii) a new term should be used to refer to these side effects (post-COVID-19 vaccination syndrome, PCVS, colloquially "post-COVIDvac-syndrome"), and that (iii) there is a need to distinguish between acute COVID-19 vaccination syndrome (ACVS) and post-acute COVID-19 vaccination syndrome (PACVS) - in analogy to acute COVID-19 and PACS ("long COVID"). Moreover, we address mixed forms of disease caused by natural SARS-CoV-2 infection and COVID-19 vaccination. We explain why it is important for medical diagnosis, care and research to use the new terms (PCVS, ACVS and PACVS) in order to avoid confusion and misinterpretation of the underlying causes of disease and to enable optimal medical therapy. We do not recommend to use the term "Post-Vac-Syndrome" as it is imprecise. The article also serves to address the current problem of "medical gaslighting" in relation to PACS and PCVS by raising awareness among the medical professionals and supplying appropriate terminology for disease.
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Affiliation(s)
- Felix Scholkmann
- University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland.
| | - Christian-Albrecht May
- Department of Anatomy, Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
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Hung CT, Hsu H. Microsurgical complication associated with vaccine-induced immune thrombotic thrombocytopenia (VITT): A case report. Medicine (Baltimore) 2023; 102:e33013. [PMID: 36800613 PMCID: PMC9936026 DOI: 10.1097/md.0000000000033013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
RATIONALE The use of ChAdOx1 nCoV-19 (Astra Zeneca) vaccine has proven beneficial, but in a limited number of the general population, it was found to be associated with vaccine-induced immune thrombotic thrombocytopenia (VITT). However, there have been no reports of this complication occurring in a microsurgical free tissue transfer. PATIENT CONCERNS A 49-year-old man developed an acute myocardial infarction 3 weeks after receiving his first dose of ChAdOx1 nCoV-19 in June 2021. Three months later, he presented with right third toe wet gangrene with extension into the plantar foot nine days after receiving his second dose of ChAdOx1 nCoV-19 vaccine. DIAGNOSIS Based on recent exposure to vaccination, the timing of inoculation before the development of his symptoms, and serology tests (platelet, D-dimer, and anti-PF4 antibodies), the patient was diagnosed with VITT. INTERVENTIONS Fasciectomy and sequestrectomy were performed for wound bed preparation. Limb salvage was done using free vastus lateralis muscle flap and skin graft for reconstruction. OUTCOME The flap was complicated by persistent microthrombi leading to superficial necrosis without vascular pedicle compromise. Repeated debridement of the superficial necrosis was done. Three months after the development of VITT, no further new superficial necrosis was seen. A well-contoured flap was seen 5 months after the initial surgery. LESSONS We believe this is the first case describing microthrombi in the free flap due to VITT after microsurgical reconstruction. Patients and surgeons should be advised of this possible risk when contemplating microsurgery once VITT has developed after ChAdOx1 nCoV-19 administration.
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Affiliation(s)
- Chen-Ting Hung
- Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Honda Hsu
- Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- * Correspondence: Honda Hsu, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Taiwan (e-mail: )
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Urano T, Yasumoto A, Yokoyama K, Horiuchi H, Morishita E, Suzuki Y. COVID-19 and Thrombosis: Clinical Aspects. Curr Drug Targets 2022; 23:1567-1572. [PMID: 36200150 DOI: 10.2174/1389450123666221005092350] [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: 05/04/2022] [Revised: 08/30/2022] [Accepted: 09/09/2022] [Indexed: 01/25/2023]
Abstract
In coronavirus disease 2019 (COVID-19), thrombus formation is related to the pathogenesis of acute respiratory distress syndrome (ARDS) and the progression of clinical symptoms. Severe damage to vascular endothelial cells and the associated cytokine storm after SARS-CoV-2 infection cause thrombogenesis and contribute to the development of more severe and unique thromboses compared to other infectious diseases. Thromboses occur more often in critically ill patients. In addition to pulmonary thromboembolism (PE) and deep vein thrombosis, acute myocardial infarction, peripheral arterial thrombosis, and aortic thrombosis have also been reported. In PE, thrombi develop in both pulmonary arteries and alveolar capillaries. These, together with intraalveolar fibrin deposition, interfere with effective gaseous exchange in the lungs and exacerbate the clinical symptoms of ARDS in patients with COVID-19. Pharmacological thromboprophylaxis is recommended for all hospitalized patients to prevent both thrombosis and aggravation of ARDS, and other organ failures. Although the pediatric population is mostly asymptomatic or develops mild disease after SARS-CoV-2 infection, a new inflammatory disorder affecting the cardiovascular system, multisystem inflammatory syndrome in children (MIS-C), has been reported. Similar to Kawasaki disease, acute myocarditis, coronary vasculitis, and aneurysms are typically seen in MISC, although these two are now considered distinct entities. A similar acute myocarditis is also observed in young male adults, in which a hyperinflammatory state after SARS-CoV-2 infection seems to be involved. Several side effects following vaccination against COVID-19 have been reported, including vaccine-induced immune thrombotic thrombocytopenia and acute myocarditis. Although these could be serious and life-threatening, the cases are very rare, thus, the benefits of immunization still outweigh the risks.
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Affiliation(s)
- Tetsumei Urano
- Department of Medical Physiology, Hamamatsu University School of Medicine, Hamamatsu, Japan.,Shizuoka Graduate University of Public Health, Shizuoka, Japan
| | - Atsushi Yasumoto
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sappero, Japan
| | - Kenji Yokoyama
- Department of Hematology/Oncology, Tokai University, Tokyo, Japan
| | - Hisanori Horiuchi
- Department of Molecular and Cellular Biology, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Eriko Morishita
- Department of Clinical Laboratory Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Faculty of Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Yuko Suzuki
- Department of Medical Physiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Portal Vein and Mesenteric Artery Thrombosis Following the Administration of an Ad26.COV2-S Vaccine—First Case from Romania: A Case Report. Vaccines (Basel) 2022; 10:vaccines10111950. [DOI: 10.3390/vaccines10111950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
COVID-19 has significantly affected public health, social life, and economies worldwide. The only effective way to combat the pandemic is through vaccines. Although the vaccines have been in use for some time, safety concerns have still been raised. The most typical adverse effects of receiving a COVID-19 vaccine are localized reactions near the injection site, followed by general physical symptoms such as headaches, fatigue, muscle pain, and fever. Additionally, some people may experience VITT (vaccine-induced immune thrombotic thrombocytopenia), a rare side effect after vaccination. We present the case of a 60-year-old female patient that developed VITT-like symptoms with spleno-portal thrombosis and intestinal ischemia two weeks after the administration of the Ad26.COV2-S vaccine. Surgical treatment consisted of extensive bowel resection with end jejunostomy and feeding ileostomy. Two weeks after the first operation, a duodenal-ileal anastomosis was performed. The patient was discharged five weeks after the onset of the symptoms. Although some rare adverse effects are associated with the SARS-CoV-2 vaccines, the risk of hospitalization from these harmful effects is lower than the risk of hospitalization from COVID-19. Therefore, recognizing VITT is significant for ensuring the early treatment of clots and proper follow-up.
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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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11
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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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12
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Kanack AJ, Padmanabhan A. Vaccine-induced immune thrombotic thrombocytopenia. Best Pract Res Clin Haematol 2022; 35:101381. [PMID: 36494147 PMCID: PMC9467921 DOI: 10.1016/j.beha.2022.101381] [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: 07/14/2022] [Revised: 09/02/2022] [Accepted: 09/02/2022] [Indexed: 12/14/2022]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is primarily a complication of adenoviral vector-based covid-19 vaccination. In VITT, thrombocytopenia and thrombosis mediated by anti-platelet factor 4 (PF4) antibodies can be severe, often characterized by thrombosis at unusual sites such as the cerebral venous sinus and splanchnic circulation. Like in heparin-induced thrombocytopenia (HIT) and spontaneous HIT, VITT antibodies recognize PF4-polyanion complexes and activate PF4-treated platelets but additionally bind to un-complexed PF4, a critical finding that could be leveraged for more specific detection of VITT. Intravenous immunoglobulin and non-heparin-based anticoagulation remain the mainstay of treatment. Second dose/boosters of mRNA covid-19 vaccines appear safe in patients with adenoviral vector-associated VITT. Emerging data is consistent with the possibility that ultra-rare cases of VITT may be seen in the setting of mRNA and virus-like particle (VLP) technology-based vaccinations and until more data is available, it is prudent to consider VITT in the differential diagnosis of all post-vaccine thrombosis and thrombocytopenia reactions.
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Affiliation(s)
- Adam J Kanack
- Division of Experimental Pathology, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, United States.
| | - Anand Padmanabhan
- Divisions of Hematopathology, Transfusion Medicine & Experimental Pathology, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, United States.
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