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Yang C, Wang I, Chitkara A, Swankutty J, Patel R, Kubba SV. Anti-PF4 antibodies and their relationship with COVID infection. Hematol Transfus Cell Ther 2024; 46:516-523. [PMID: 38388299 DOI: 10.1016/j.htct.2023.11.012] [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: 06/02/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 02/24/2024] Open
Abstract
Detecting anti-PF4 antibodies remains the golden diagnostic method for heparin-induced thrombocytopenia (HIT) diagnosis with high sensitivity and specificity. Various lab tests detect anti-PF4 antibodies, including immunoassays and functional assays. Even with positive detection of the anti-PF4 antibody, several factors are involved in the result. The concept of anti-PF4 disorders was recently brought to light during the COVID pandemic since the development of vaccine-induced thrombotic thrombocytopenia (VITT) with the adenovirus-vectored-DNA vaccine during the pandemic. Circumstances that detect anti-PF4 antibodies are classified as anti-PF4 disorders, including VITT, autoimmune HIT and spontaneous HIT. Some studies showed a higher percentage of anti-PF4 antibody detection among the population infected by COVID-19 without heparin exposure and some supported the theory that the anti-PF4 antibodies were related to the disease severity. In this review article, we provide a brief review of anti-PF4 disorders and summarize the current studies of anti-PF4 antibodies and COVID-19 infection.
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Affiliation(s)
- Chieh Yang
- School of Medicine, University of California Riverside, USA
| | - Irene Wang
- School of Medicine, University of California Riverside, USA
| | | | | | | | - Samir V Kubba
- School of Medicine, University of California Riverside, USA.
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2
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d’Almeida S, Markovic S, Hermann P, Bracht H, Peifer J, Ettrich TJ, Imhof A, Zhou S, Weiss M, Viardot A, Rottbauer W, Dahme T. Thromboembolism after Astra Zeneca COVID-19 vaccine: Not always PF4- antibody mediated. Hum Vaccin Immunother 2023; 19:2252239. [PMID: 37655367 PMCID: PMC10478733 DOI: 10.1080/21645515.2023.2252239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/26/2023] [Accepted: 08/11/2023] [Indexed: 09/02/2023] Open
Abstract
Cases of thromboembolic events in 2021 flared up the discussion about the safety of Astra Zeneca's AZD1222 vaccine. We hereby report three cases of pulmonary embolism (PE), one case of extended portal vein thrombosis, and one case of combined portal vein thrombosis and PE within 2 weeks after vaccination with the Astra Zeneca AZD1222 vaccine in a 60-year-old, a 50-year old, a 33-year-old, a 30-year old, and a 40-year-old male in that year. All patients were healthy before. In three patients, we observed thrombocytopenia and to some extent unusually low antibody levels for the Spike Protein (S-protein), while the other two had normal thrombocyte counts. Only one patient had anti-platelet factor 4 (PF4)-antibodies detectable as it has been described in the "heparin-induced thrombocytopenia (HIT)-like" disease of "vaccine-induced prothrombotic immune thrombocytopenia" (VIPIT) and we therefore assume that heterogeneous mechanisms led to PE. Therefore, we advise to collect and report more cases, in order to determine the age-related risks of vaccination balanced against the benefits of immunity to SARS-COV-2 for the AZD1222 vaccine in order to gain knowledge for the next pandemic.
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Affiliation(s)
- Sascha d’Almeida
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Sinisa Markovic
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Patrick Hermann
- Department of Medicine I, Ulm University Medical Center, Ulm, Germany
| | - Hendrik Bracht
- Central Emergency Department, Ulm University Medical Center, Ulm, Germany
| | - Johannes Peifer
- Central Emergency Department, Ulm University Medical Center, Ulm, Germany
| | - Thomas J. Ettrich
- Department of Medicine I, Ulm University Medical Center, Ulm, Germany
| | - Armin Imhof
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
| | - Shaoxia Zhou
- Department of Laboratory Medicine, Ulm University Medical Center, Ulm, Germany
| | - Manfred Weiss
- Department of Anesthesiology and Intensive Care, Ulm University Medical Center, Ulm, Germany
| | - Andreas Viardot
- Department of Medicine III, Ulm University Medical Center, Ulm, Germany
| | | | - Tillman Dahme
- Department of Medicine II, Ulm University Medical Center, Ulm, Germany
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3
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Rostami M, Mansouritorghabeh H. Significance of heparin induced thrombocytopenia (HIT) in COVID-19: a systematic review and meta-analysis. J Thromb Thrombolysis 2023:10.1007/s11239-023-02827-5. [PMID: 37219826 DOI: 10.1007/s11239-023-02827-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 05/24/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) occurs in approximately 3% of patients receiving heparinoids. About 30-75% of patients with type 2 of HIT develop thrombosis as a result of platelet activation. The most important clinical symptom is thrombocytopenia. Patients with severe COVID-19 are among those receiving heparinoids. This meta-analysis performed to picture the current knowledge and results of published studies in this field. Three search engines were searched and 575 papers were found. After evaluation, 37 articles were finally selected of which 13 studies were quantitatively analyzed. The pooled frequency rate of suspected cases with HIT in 13 studies with 11,241 patients was 1.7%. The frequency of HIT was 8.2% in the extracorporeal membrane oxygenation subgroup with 268 patients and 0.8% in the hospitalization subgroup with 10,887 patients. The coincidence of these two conditions may increase the risk of thrombosis. Of the 37 patients with COVID-19 and confirmed HIT, 30 patients (81%) were treated in the intensive care unit or had severe COVID-19. The most commonly used anticoagulants were UFH in 22 cases (59.4%). The median platelet count before treatment was 237 (176-290) x 103/µl and the median nadir platelet count was 52 (31-90.5) x 103/µl.
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Affiliation(s)
- Mehrdad Rostami
- MSc of Hematology & Blood Banking, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hassan Mansouritorghabeh
- Central Diagnostic laboratories, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran., Ghaem Hospital, Mashhad University of Medical Sciences, P.O. Box: 91766-99199, Mashhad, Iran.
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Kolb P, Giese S, Voll RE, Hengel H, Falcone V. Immune complexes as culprits of immunopathology in severe COVID-19. Med Microbiol Immunol 2023; 212:185-191. [PMID: 35871171 PMCID: PMC9308473 DOI: 10.1007/s00430-022-00743-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/15/2022] [Indexed: 02/07/2023]
Abstract
Infection with the pandemic human coronavirus SARS-CoV-2 elicits a respiratory tract disease, termed Coronavirus disease 2019 (COVID-19). While a variable degree of disease-associated symptoms may emerge, severe COVID-19 is commonly associated with respiratory complications such as acute respiratory distress syndrome (ARDS), the necessity for mechanical ventilation or even extracorporeal membrane oxygenation (ECMO). Amongst others, disease outcome depends on age and pre-existing conditions like cardiovascular diseases, metabolic disorders but also age and biological sex. Intriguingly, increasing experimental and clinical evidence suggests that an exacerbated inflammatory response and in particular IgG immune complexes (ICs), significantly contribute to severe and prolonged COVID-19 disease progression. Vast amounts of deposited, unresolved ICs in tissue are capable to initiate an exaggerated Fc gamma receptor (FcγR) mediated signalling cascade which eventually results in common IC-associated organ diseases such as vasculitis, glomerulonephritis and arthritis, comorbidities that have been frequently reported for COVID-19. Moreover and independent of deposited ICs, very recent work identified soluble ICs (sIC) to be also present in the circulation of a majority of severely ill patients, where their systemic abundance correlated with disease severity. Thus, detection of circulating sICs in patients represents a potential marker for critical COVID-19 disease progression. Their detection early after clinical deterioration might become an indicator for the requirement of prompt anti-inflammatory treatment. Here, we review the role of ICs in COVID-19 progression, their possible origins and potential intervention strategies.
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Affiliation(s)
- Philipp Kolb
- Faculty of Medicine, Institute of Virology, Freiburg University Medical Center, Albert-Ludwigs-University of Freiburg, Freiburg, Germany.
| | - Sebastian Giese
- Faculty of Medicine, Institute of Virology, Freiburg University Medical Center, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Reinhard Edmund Voll
- Faculty of Medicine, Department of Rheumatology and Clinical Immunology, Freiburg University Medical Center, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Hartmut Hengel
- Faculty of Medicine, Institute of Virology, Freiburg University Medical Center, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Valeria Falcone
- Faculty of Medicine, Institute of Virology, Freiburg University Medical Center, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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Root-Bernstein R. From Co-Infections to Autoimmune Disease via Hyperactivated Innate Immunity: COVID-19 Autoimmune Coagulopathies, Autoimmune Myocarditis and Multisystem Inflammatory Syndrome in Children. Int J Mol Sci 2023; 24:ijms24033001. [PMID: 36769320 PMCID: PMC9917907 DOI: 10.3390/ijms24033001] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Neutrophilia and the production of neutrophil extracellular traps (NETs) are two of many measures of increased inflammation in severe COVID-19 that also accompany its autoimmune complications, including coagulopathies, myocarditis and multisystem inflammatory syndrome in children (MIS-C). This paper integrates currently disparate measures of innate hyperactivation in severe COVID-19 and its autoimmune complications, and relates these to SARS-CoV-2 activation of innate immunity. Aggregated data include activation of Toll-like receptors (TLRs), nucleotide-binding oligomerization domain (NOD) receptors, NOD leucine-rich repeat and pyrin-domain-containing receptors (NLRPs), retinoic acid-inducible gene I (RIG-I) and melanoma-differentiation-associated gene 5 (MDA-5). SARS-CoV-2 mainly activates the virus-associated innate receptors TLR3, TLR7, TLR8, NLRP3, RIG-1 and MDA-5. Severe COVID-19, however, is characterized by additional activation of TLR1, TLR2, TLR4, TLR5, TLR6, NOD1 and NOD2, which are primarily responsive to bacterial antigens. The innate activation patterns in autoimmune coagulopathies, myocarditis and Kawasaki disease, or MIS-C, mimic those of severe COVID-19 rather than SARS-CoV-2 alone suggesting that autoimmunity follows combined SARS-CoV-2-bacterial infections. Viral and bacterial receptors are known to synergize to produce the increased inflammation required to support autoimmune disease pathology. Additional studies demonstrate that anti-bacterial antibodies are also required to account for known autoantigen targets in COVID-19 autoimmune complications.
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De Michele M, Lorenzano S, Piscopo P, Rivabene R, Crestini A, Chistolini A, Stefanini L, Pulcinelli FM, Berto I, Campagna R, Amisano P, Iacobucci M, Cirelli C, Falcou A, Nicolini E, Schiavo OG, Toni D. SARS-CoV-2 infection predicts larger infarct volume in patients with acute ischemic stroke. Front Cardiovasc Med 2023; 9:1097229. [PMID: 36704480 PMCID: PMC9871539 DOI: 10.3389/fcvm.2022.1097229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
Background and purpose Acute ischemic stroke (AIS) is a fearful complication of Coronavirus Disease-2019 (COVID-19). Aims of this study were to compare clinical/radiological characteristics, endothelial and coagulation dysfunction between acute ischemic stroke (AIS) patients with and without COVID-19 and to investigate if and how the SARS-CoV-2 spike protein (SP) was implicated in triggering platelet activation. Methods We enrolled AIS patients with COVID-19 within 12 h from onset and compared them with an age- and sex-matched cohort of AIS controls without COVID-19. Neuroimaging studies were performed within 24 h. Blood samples were collected in a subset of 10 patients. Results Of 39 AIS patients, 22 had COVID-19 and 17 did not. Admission levels of Factor VIII and von Willebrand factor antigen were significantly higher in COVID-19 patients and positively correlated with the infarct volume. In multivariate linear regression analyses, COVID-19 was an independent predictor of infarct volume (B 20.318, Beta 0.576, 95%CI 6.077-34.559; p = 0.011). SP was found in serum of 2 of the 10 examined COVID-19 patients. Platelets from healthy donors showed a similar degree of procoagulant activation induced by COVID-19 and non-COVID-19 patients' sera. The anti-SP and anti-FcγRIIA blocking antibodies had no effect in modulating platelet activity in both groups. Conclusions SARS-CoV-2 infection seems to play a major role in endothelium activation and infarct volume extension during AIS.
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Affiliation(s)
- Manuela De Michele
- Emergency Department, Stroke Unit, Sapienza University of Rome, Rome, Italy
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Paola Piscopo
- Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Roberto Rivabene
- Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Alessio Crestini
- Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Antonio Chistolini
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Lucia Stefanini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Fabio M. Pulcinelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Irene Berto
- Emergency Department, Stroke Unit, Sapienza University of Rome, Rome, Italy
| | - Roberta Campagna
- Department of Molecular Medicine, Laboratory of Virology, Sapienza University of Rome, Rome, Italy
| | - Paolo Amisano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Marta Iacobucci
- Neuroradiology Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Carlo Cirelli
- Neuroradiology Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Anne Falcou
- Emergency Department, Stroke Unit, Sapienza University of Rome, Rome, Italy
| | - Ettore Nicolini
- Emergency Department, Stroke Unit, Sapienza University of Rome, Rome, Italy
| | - Oscar G. Schiavo
- Emergency Department, Stroke Unit, Sapienza University of Rome, Rome, Italy
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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Devaux CA, Camoin-Jau L. An update on angiotensin-converting enzyme 2 structure/functions, polymorphism, and duplicitous nature in the pathophysiology of coronavirus disease 2019: Implications for vascular and coagulation disease associated with severe acute respiratory syndrome coronavirus infection. Front Microbiol 2022; 13:1042200. [PMID: 36519165 PMCID: PMC9742611 DOI: 10.3389/fmicb.2022.1042200] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/07/2022] [Indexed: 08/01/2023] Open
Abstract
It has been known for many years that the angiotensin-converting enzyme 2 (ACE2) is a cell surface enzyme involved in the regulation of blood pressure. More recently, it was proven that the severe acute respiratory syndrome coronavirus (SARS-CoV-2) interacts with ACE2 to enter susceptible human cells. This functional duality of ACE2 tends to explain why this molecule plays such an important role in the clinical manifestations of coronavirus disease 2019 (COVID-19). At the very start of the pandemic, a publication from our Institute (entitled "ACE2 receptor polymorphism: susceptibility to SARS-CoV-2, hypertension, multi-organ failure, and COVID-19 disease outcome"), was one of the first reviews linking COVID-19 to the duplicitous nature of ACE2. However, even given that COVID-19 pathophysiology may be driven by an imbalance in the renin-angiotensin system (RAS), we were still far from understanding the complexity of the mechanisms which are controlled by ACE2 in different cell types. To gain insight into the physiopathology of SARS-CoV-2 infection, it is essential to consider the polymorphism and expression levels of the ACE2 gene (including its alternative isoforms). Over the past 2 years, an impressive amount of new results have come to shed light on the role of ACE2 in the pathophysiology of COVID-19, requiring us to update our analysis. Genetic linkage studies have been reported that highlight a relationship between ACE2 genetic variants and the risk of developing hypertension. Currently, many research efforts are being undertaken to understand the links between ACE2 polymorphism and the severity of COVID-19. In this review, we update the state of knowledge on the polymorphism of ACE2 and its consequences on the susceptibility of individuals to SARS-CoV-2. We also discuss the link between the increase of angiotensin II levels among SARS-CoV-2-infected patients and the development of a cytokine storm associated microvascular injury and obstructive thrombo-inflammatory syndrome, which represent the primary causes of severe forms of COVID-19 and lethality. Finally, we summarize the therapeutic strategies aimed at preventing the severe forms of COVID-19 that target ACE2. Changing paradigms may help improve patients' therapy.
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Affiliation(s)
- Christian A. Devaux
- Aix-Marseille Université, IRD, APHM, MEPHI, IHU–Méditerranée Infection, Marseille, France
- Center National de la Recherche Scientifique, Marseille, France
| | - Laurence Camoin-Jau
- Aix-Marseille Université, IRD, APHM, MEPHI, IHU–Méditerranée Infection, Marseille, France
- Laboratoire d’Hématologie, Hôpital de La Timone, APHM, Boulevard Jean-Moulin, Marseille, France
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8
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Liu Q, Miao H, Li S, Zhang P, Gerber GF, Follmann D, Ji H, Zeger SL, Chertow DS, Quinn TC, Robinson ML, Kickler TS, Rothman RE, Fenstermacher KZJ, Braunstein EM, Cox AL, Farci P, Fauci AS, Lusso P. Anti-PF4 antibodies associated with disease severity in COVID-19. Proc Natl Acad Sci U S A 2022; 119:e2213361119. [PMID: 36322776 PMCID: PMC9704720 DOI: 10.1073/pnas.2213361119] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 09/12/2022] [Indexed: 08/06/2023] Open
Abstract
Severe COVID-19 is characterized by a prothrombotic state associated with thrombocytopenia, with microvascular thrombosis being almost invariably present in the lung and other organs at postmortem examination. We evaluated the presence of antibodies to platelet factor 4 (PF4)-polyanion complexes using a clinically validated immunoassay in 100 hospitalized patients with COVID-19 with moderate or severe disease (World Health Organization score, 4 to 10), 25 patients with acute COVID-19 visiting the emergency department, and 65 convalescent individuals. Anti-PF4 antibodies were detected in 95 of 100 hospitalized patients with COVID-19 (95.0%) irrespective of prior heparin treatment, with a mean optical density value of 0.871 ± 0.405 SD (range, 0.177 to 2.706). In contrast, patients hospitalized for severe acute respiratory disease unrelated to COVID-19 had markedly lower levels of the antibodies. In a high proportion of patients with COVID-19, levels of all three immunoglobulin (Ig) isotypes tested (IgG, IgM, and IgA) were simultaneously elevated. Antibody levels were higher in male than in female patients and higher in African Americans and Hispanics than in White patients. Anti-PF4 antibody levels were correlated with the maximum disease severity score and with significant reductions in circulating platelet counts during hospitalization. In individuals convalescent from COVID-19, the antibody levels returned to near-normal values. Sera from patients with COVID-19 induced higher levels of platelet activation than did sera from healthy blood donors, but the results were not correlated with the levels of anti-PF4 antibodies. These results demonstrate that the vast majority of patients with severe COVID-19 develop anti-PF4 antibodies, which may play a role in the clinical complications of COVID-19.
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Affiliation(s)
- Qingbo Liu
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Huiyi Miao
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Shuai Li
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Peng Zhang
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Gloria F. Gerber
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287
| | - Dean Follmann
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Hongkai Ji
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Scott L. Zeger
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Daniel S. Chertow
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
- Emerging Pathogens Section, Critical Care Medicine Department, Clinical Center, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Thomas C. Quinn
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| | - Matthew L. Robinson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| | - Thomas S. Kickler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287
| | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287
| | | | - Evan M. Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287
| | - Andrea L. Cox
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| | - Patrizia Farci
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Anthony S. Fauci
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
| | - Paolo Lusso
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892
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Sharma S, Tyagi T, Antoniak S. Platelet in thrombo-inflammation: Unraveling new therapeutic targets. Front Immunol 2022; 13:1039843. [PMID: 36451834 PMCID: PMC9702553 DOI: 10.3389/fimmu.2022.1039843] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
In the broad range of human diseases, thrombo-inflammation appears as a clinical manifestation. Clinically, it is well characterized in context of superficial thrombophlebitis that is recognized as thrombosis and inflammation of superficial veins. However, it is more hazardous when developed in the microvasculature of injured/inflamed/infected tissues and organs. Several diseases like sepsis and ischemia-reperfusion can cause formation of microvascular thrombosis subsequently leading to thrombo-inflammation. Thrombo-inflammation can also occur in cases of antiphospholipid syndrome, preeclampsia, sickle cell disease, bacterial and viral infection. One of the major contributors to thrombo-inflammation is the loss of normal anti-thrombotic and anti-inflammatory potential of the endothelial cells of vasculature. This manifest itself in the form of dysregulation of the coagulation pathway and complement system, pathologic platelet activation, and increased recruitment of leukocyte within the microvasculature. The role of platelets in hemostasis and formation of thrombi under pathologic and non-pathologic conditions is well established. Platelets are anucleate cells known for their essential role in primary hemostasis and the coagulation pathway. In recent years, studies provide strong evidence for the critical involvement of platelets in inflammatory processes like acute ischemic stroke, and viral infections like Coronavirus disease 2019 (COVID-19). This has encouraged the researchers to investigate the contribution of platelets in the pathology of various thrombo-inflammatory diseases. The inhibition of platelet surface receptors or their intracellular signaling which mediate initial platelet activation and adhesion might prove to be suitable targets in thrombo-inflammatory disorders. Thus, the present review summarizes the concept and mechanism of platelet signaling and briefly discuss their role in sterile and non-sterile thrombo-inflammation, with the emphasis on role of platelets in COVID-19 induced thrombo-inflammation. The aim of this review is to summarize the recent developments in deciphering the role of the platelets in thrombo-inflammation and discuss their potential as pharmaceutical targets.
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Affiliation(s)
- Swati Sharma
- UNC Blood Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Tarun Tyagi
- Yale Cardiovascular Research Center, Yale School of Medicine, New Haven, CT, United States
| | - Silvio Antoniak
- UNC Blood Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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10
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Root-Bernstein R, Huber J, Ziehl A. Complementary Sets of Autoantibodies Induced by SARS-CoV-2, Adenovirus and Bacterial Antigens Cross-React with Human Blood Protein Antigens in COVID-19 Coagulopathies. Int J Mol Sci 2022; 23:ijms231911500. [PMID: 36232795 PMCID: PMC9569991 DOI: 10.3390/ijms231911500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 12/11/2022] Open
Abstract
COVID-19 patients often develop coagulopathies including microclotting, thrombotic strokes or thrombocytopenia. Autoantibodies are present against blood-related proteins including cardiolipin (CL), serum albumin (SA), platelet factor 4 (PF4), beta 2 glycoprotein 1 (β2GPI), phosphodiesterases (PDE), and coagulation factors such as Factor II, IX, X and von Willebrand factor (vWF). Different combinations of autoantibodies associate with different coagulopathies. Previous research revealed similarities between proteins with blood clotting functions and SARS-CoV-2 proteins, adenovirus, and bacterial proteins associated with moderate-to-severe COVID-19 infections. This study investigated whether polyclonal antibodies (mainly goat and rabbit) against these viruses and bacteria recognize human blood-related proteins. Antibodies against SARS-CoV-2 and adenovirus recognized vWF, PDE and PF4 and SARS-CoV-2 antibodies also recognized additional antigens. Most bacterial antibodies tested (group A streptococci [GAS], staphylococci, Escherichia coli [E. coli], Klebsiella pneumoniae, Clostridia, and Mycobacterium tuberculosis) cross-reacted with CL and PF4. while GAS antibodies also bound to F2, Factor VIII, Factor IX, and vWF, and E. coli antibodies to PDE. All cross-reactive interactions involved antibody-antigen binding constants smaller than 100 nM. Since most COVID-19 coagulopathy patients display autoantibodies against vWF, PDE and PF4 along with CL, combinations of viral and bacterial infections appear to be necessary to initiate their autoimmune coagulopathies.
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11
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Draxler DF, Brodard J, Zante B, Jakob SM, Wiegand J, Kremer Hovinga JA, Angelillo-Scherrer A, Rovo A. The potential impact of Covid-19 on the capacity of routine laboratory tests to detect heparin-induced thrombocytopenia. Thromb J 2022; 20:55. [PMID: 36163073 PMCID: PMC9510722 DOI: 10.1186/s12959-022-00411-0] [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: 03/21/2022] [Accepted: 09/04/2022] [Indexed: 11/24/2022] Open
Abstract
In Covid-19, anticoagulation with heparin is often administered to prevent or treat thromboembolic events. Heparin-induced thrombocytopenia (HIT) is a severe complication of heparin treatment, caused by heparin-dependent, platelet activating anti-platelet factor 4 (PF4)/heparin antibodies. Diagnosis of HIT is based on the combination of clinical parameters, allowing to determine the pretest probability, and laboratory testing for anti-PF4/heparin antibodies and confirmatory functional assays, such as the heparin-induced platelet activation (HIPA) test. We report the case of a patient with severe Covid-19 pneumonia requiring ECMO treatment, who developed recurrent clotting of the ECMO filter and a drop in platelet count under heparin treatment. He was therefore suspected to have HIT and the anticoagulation was switched to argatroban. Despite high clinical probability and high titres of anti-PF4/heparin antibodies, the functional HIPA test was negative. Nevertheless, argatroban was continued rather than to reinstate anticoagulation with heparin. Reevaluation 7 days later then demonstrated a strongly positive functional HIPA test and confirmed the diagnosis of HIT. Under anticoagulation with argatroban the patient gradually improved and was finally weaned off the ECMO. In conclusion, this case highlights the critical importance of clinical judgement, exploiting the 4 T score, given that Covid-19 patients may present a different pattern of routine laboratory test results in HIT diagnostics. The possibility of a false negative HIPA test has to be considered, particularly in early phases of presentation. In cases of a discrepancy with high clinical probability of HIT and/or high titre anti-PF4/heparin antibodies despite a negative HIPA test, a reevaluation within 3 to 5 days after the initial test should be considered in order to avoid precipitant reestablishment of unfractionated heparin, with potentially fatal consequences.
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Affiliation(s)
- Dominik F Draxler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Bern Center for Precision Medicine, Bern, Switzerland.
| | - Justine Brodard
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Björn Zante
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Wiegand
- Department of Intensive Care Medicine, Lindenhofspital, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Bern Center for Precision Medicine, Bern, Switzerland
| | - Alicia Rovo
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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12
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Kruger A, Vlok M, Turner S, Venter C, Laubscher GJ, Kell DB, Pretorius E. Proteomics of fibrin amyloid microclots in long COVID/post-acute sequelae of COVID-19 (PASC) shows many entrapped pro-inflammatory molecules that may also contribute to a failed fibrinolytic system. Cardiovasc Diabetol 2022; 21:190. [PMID: 36131342 PMCID: PMC9491257 DOI: 10.1186/s12933-022-01623-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/07/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Post-acute sequelae of COVID-19 (PASC), also now known as long COVID, has become a major global health and economic burden. Previously, we provided evidence that there is a significant insoluble fibrin amyloid microclot load in the circulation of individuals with long COVID, and that these microclots entrap a substantial number of inflammatory molecules, including those that might prevent clot breakdown. Scientifically, the most challenging aspect of this debilitating condition is that traditional pathology tests such as a serum CRP (C-reactive protein) may not show any significant abnormal inflammatory markers, albeit these tests measure only the soluble inflammatory molecules. Elevated, or abnormal soluble biomarkers such as IL-6, D-Dimer or fibrinogen indicate an increased risk for thrombosis or a host immune response in COVID-19. The absence of biomarkers in standard pathology tests, result in a significant amount of confusion for patients and clinicians, as patients are extremely sick or even bed-ridden but with no regular identifiable reason for their disease. Biomarkers that are currently available cannot detect the molecules present in the microclots we identified and are therefore unable to confirm their presence or the mechanisms that drive their formation. METHODS Here we analysed the protein content of double-digested microclots of 99 long COVID patients and 29 healthy controls. The patients suffering from long COVID reported their symptoms through a questionnaire completed by themselves or their attending physician. RESULTS Our long COVID cohort's symptoms were found to be in line with global findings, where the most prevalent symptoms were constant fatigue (74%,) cognitive impairment (71%) and depression and anxiety (30%). Our most noteworthy findings were a reduced level of plasma Kallikrein compared to our controls, an increased level of platelet factor 4 (PF4) von Willebrand factor (VWF), and a marginally increased level of α-2 antiplasmin (α-2-AP). We also found a significant presence of antibodies entrapped inside these microclots. CONCLUSION Our results confirm the presence of pro-inflammatory molecules that may also contribute to a failed fibrinolysis phenomenon, which could possibly explain why individuals with long COVID suffer from chronic fatigue, dyspnoea, or cognitive impairment. In addition, significant platelet hyperactivation was noted. Hyperactivation will result in the granular content of platelets being shed into the circulation, including PF4. Overall, our results provide further evidence of both a failed fibrinolytic system in long COVID/PASC and the entrapment of many proteins whose presence might otherwise go unrecorded. These findings might have significant implications for individuals with pre-existing comorbidities, including cardiovascular disease and type 2 diabetes.
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Affiliation(s)
- Arneaux Kruger
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch, 7602, South Africa
| | - Mare Vlok
- Central Analytical Facility, Mass Spectrometry Stellenbosch University, Tygerberg Campus, Room 6054, Clinical Building, Francie Van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Simone Turner
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch, 7602, South Africa
| | - Chantelle Venter
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch, 7602, South Africa
| | | | - Douglas B Kell
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch, 7602, South Africa.
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, L69 7ZB, UK.
- The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, Kemitorvet 200, 2800, Kongens Lyngby, Denmark.
| | - Etheresia Pretorius
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Private Bag X1 Matieland, Stellenbosch, 7602, South Africa.
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, L69 7ZB, UK.
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13
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Nasonov EL, Samsonov MY, Lila AM. Coronavirus Infection 2019 (COVID-19) and Autoimmunity. HERALD OF THE RUSSIAN ACADEMY OF SCIENCES 2022; 92:398-403. [PMID: 36091857 PMCID: PMC9447958 DOI: 10.1134/s1019331622040062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/11/2022] [Accepted: 03/12/2022] [Indexed: 06/15/2023]
Abstract
The pandemic of coronavirus disease 2019, etiologically associated with the SARS-CoV-2 virus, has drawn the attention of the medical community to new clinical and fundamental problems in the immunopathology of human diseases. During a detailed analysis of the clinical manifestations and immunopathological disorders in COVID-19, it became apparent that SARS-CoV-2 infection is accompanied by the development of a wide range of extrapulmonary clinical and laboratory disorders, some of which are characteristic of immunoinflammatory rheumatic diseases and other human autoimmune and autoinflammatory diseases. All this taken together served as a theoretical justification for the repositioning of anti-inflammatory drugs in COVID-19, previously specifically designed for the treatment of immunoinflammatory rheumatic diseases. The prospects for studying the autoimmune mechanisms of COVID-19 and the possibility of anti-inflammatory therapy are discussed.
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Affiliation(s)
- E. L. Nasonov
- Nasonova Research Institute of Rheumatology, Moscow, Russia
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - M. Yu. Samsonov
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - A. M. Lila
- Nasonova Research Institute of Rheumatology, Moscow, Russia
- Russian Medical Academy for Continuous Professional Education, Moscow, Russia
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14
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Angelika W, Erika GS, Michael K, Hannes S, Ingrid P, Sabine EH, Peter Q, Oswald W, Ursula W, Katharina GP. Preexisting anti-PF4 antibodies are not further triggered upon vaccination with SARS-CoV-2 vector vaccines in a cohort of 400 health care workers. Thromb Res 2022; 218:142-144. [PMID: 36037550 PMCID: PMC9367206 DOI: 10.1016/j.thromres.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/27/2022] [Accepted: 08/08/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Wagner Angelika
- Medical University of Vienna, Centre for Pathophysiology, Infectiology and Immunology, Institute of Specific Prophylaxis and Tropical Medicine, Vienna, Austria
| | - Garner-Spitzer Erika
- Medical University of Vienna, Centre for Pathophysiology, Infectiology and Immunology, Institute of Specific Prophylaxis and Tropical Medicine, Vienna, Austria
| | - Kundi Michael
- Medical University of Vienna, Centre for Public Health, Vienna, Austria
| | - Stockinger Hannes
- Medical University of Vienna, Centre for Pathophysiology, Infectiology and Immunology, Institute for Hygiene and Applied Immunology, Vienna, Austria
| | - Pabinger Ingrid
- Medical University of Vienna, Clinical Division of Hematology and Hemostaserology, Vienna, Austria
| | | | - Quehenberger Peter
- Medical University of Vienna, Department of Laboratory Medicine, Vienna, Austria
| | - Wagner Oswald
- Medical University of Vienna, Department of Laboratory Medicine, Vienna, Austria
| | - Wiedermann Ursula
- Medical University of Vienna, Centre for Pathophysiology, Infectiology and Immunology, Institute of Specific Prophylaxis and Tropical Medicine, Vienna, Austria.
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15
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Mellema RA, Crandell J, Petrey AC. Platelet Dysregulation in the Pathobiology of COVID-19. Hamostaseologie 2022; 42:221-228. [PMID: 34879421 DOI: 10.1055/a-1646-3392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) encompasses a broad spectrum of clinical manifestations caused by infection with severe acute respiratory syndrome coronavirus 2.Patients with severe disease present with hyperinflammation which can affect multiple organs which often include observations of microvascular and macrovascular thrombi. COVID-19 is increasingly recognized as a thromboinflammatory disease where alterations of both coagulation and platelets are closely linked to mortality and clinical outcomes. Although platelets are most well known as central mediators of hemostasis, they possess chemotactic molecules, cytokines, and adhesion molecules that are now appreciated as playing an important role in the regulation of immune response. This review summarizes the current knowledge of platelet alterations observed in the context of COVID-19 and their impact upon disease pathobiology.
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Affiliation(s)
- Rebecca A Mellema
- Division of Microbiology and Immunology, Department of Pathology, University of Utah, Salt Lake City, Utah, United States
| | - Jacob Crandell
- Molecular Medicine Program, University of Utah, Salt Lake City, Utah, United States
| | - Aaron C Petrey
- Division of Microbiology and Immunology, Department of Pathology, University of Utah, Salt Lake City, Utah, United States
- Molecular Medicine Program, University of Utah, Salt Lake City, Utah, United States
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16
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Karnes JH, Rollin J, Giles JB, Martinez KL, Steiner HE, Shaffer CM, Momozawa Y, Inai C, Bombin A, Shi M, Mosley JD, Stanaway I, Selleng K, Thiele T, Mushiroda T, Pouplard C, Heddle NM, Kubo M, Phillips EJ, Warkentin TE, Gruel Y, Greinacher A, Roden DM. ABO O blood group as a risk factor for platelet reactivity in heparin-induced thrombocytopenia. Blood 2022; 140:274-284. [PMID: 35377938 PMCID: PMC9305089 DOI: 10.1182/blood.2021014240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/08/2022] [Indexed: 11/20/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an unpredictable, potentially catastrophic adverse effect resulting from an immune response to platelet factor 4 (PF4)/heparin complexes. We performed a genome-wide association study (GWAS) with positive functional assay as the outcome in a large discovery cohort of patients divided into 3 groups: (1) functional assay-positive cases (n = 1269), (2) antibody-positive (functional assay-negative) controls (n = 1131), and (3) antibody-negative controls (n = 1766). Significant associations (α = 5 × 10-8) were investigated in a replication cohort (α = 0.05) of functional assay-confirmed HIT cases (n = 177), antibody-positive (function assay-negative) controls (n = 258), and antibody-negative controls (n = 351). We observed a strong association for positive functional assay with increasing PF4/heparin immunoglobulin-G (IgG) level (odds ratio [OR], 16.53; 95% confidence interval [CI], 13.83-19.74; P = 1.51 × 10-209) and female sex (OR, 1.15; 95% CI, 1.01-1.32; P = .034). The rs8176719 C insertion variant in ABO was significantly associated with positive functional assay status in the discovery cohort (frequency = 0.41; OR, 0.751; 95% CI, 0.682-0.828; P = 7.80 × 10-9) and in the replication cohort (OR, 0.467; 95% CI, 0.228-0.954; P = .0367). The rs8176719 C insertion, which encodes all non-O blood group alleles, had a protective effect, indicating that the rs8176719 C deletion and the O blood group were risk factors for HIT (O blood group OR, 1.42; 95% CI, 1.26-1.61; P = 3.09 × 10-8). Meta-analyses indicated that the ABO association was independent of PF4/heparin IgG levels and was stronger when functional assay-positive cases were compared with antibody-positive (functional assay-negative) controls than with antibody-negative controls. Sequencing and fine-mapping of ABO demonstrated that rs8176719 was the causal single nucleotide polymorphism (SNP). Our results clarify the biology underlying HIT pathogenesis with ramifications for prediction and may have important implications for related conditions, such as vaccine-induced thrombotic thrombocytopenia.
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Affiliation(s)
- Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Jerome Rollin
- Regional University Hospital Centre Tours, Department of Hemostasis, Tours, France
- University of Tours, EA7501 GICC, Tours, France
| | - Jason B Giles
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
| | - Kiana L Martinez
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
| | - Heidi E Steiner
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ
| | | | - Yukihide Momozawa
- RIKEN Center for Integrative Medical Sciences (IMS), Yokohama, Kanagawa, Japan
| | - Chihiro Inai
- RIKEN Center for Integrative Medical Sciences (IMS), Yokohama, Kanagawa, Japan
| | - Andrei Bombin
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Mingjian Shi
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan D Mosley
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ian Stanaway
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, WA
| | - Kathleen Selleng
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Taisei Mushiroda
- RIKEN Center for Integrative Medical Sciences (IMS), Yokohama, Kanagawa, Japan
| | - Claire Pouplard
- Regional University Hospital Centre Tours, Department of Hemostasis, Tours, France
- University of Tours, EA7501 GICC, Tours, France
| | - Nancy M Heddle
- Department of Medicine, McMaster University, Hamilton, ON, Canada; and
| | - Michiaki Kubo
- RIKEN Center for Integrative Medical Sciences (IMS), Yokohama, Kanagawa, Japan
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Yves Gruel
- Regional University Hospital Centre Tours, Department of Hemostasis, Tours, France
- University of Tours, EA7501 GICC, Tours, France
| | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Dan M Roden
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN
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17
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18
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de Buhr N, Baumann T, Werlein C, Fingerhut L, Imker R, Meurer M, Götz F, Bronzlik P, Kühnel MP, Jonigk DD, Ernst J, Leotescu A, Gabriel MM, Worthmann H, Lichtinghagen R, Tiede A, von Köckritz-Blickwede M, Falk CS, Weissenborn K, Schuppner R, Grosse GM. Insights Into Immunothrombotic Mechanisms in Acute Stroke due to Vaccine-Induced Immune Thrombotic Thrombocytopenia. Front Immunol 2022; 13:879157. [PMID: 35619694 PMCID: PMC9128407 DOI: 10.3389/fimmu.2022.879157] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/11/2022] [Indexed: 12/29/2022] Open
Abstract
During the COVID-19 pandemic, vaccination is the most important countermeasure. Pharmacovigilance concerns however emerged with very rare, but potentially disastrous thrombotic complications following vaccination with ChAdOx1. Platelet factor-4 antibody mediated vaccine-induced immune thrombotic thrombocytopenia (VITT) was described as an underlying mechanism of these thrombotic events. Recent work moreover suggests that mechanisms of immunothrombosis including neutrophil extracellular trap (NET) formation might be critical for thrombogenesis during VITT. In this study, we investigated blood and thrombus specimens of a female patient who suffered severe stroke due to VITT after vaccination with ChAdOx1 in comparison to 13 control stroke patients with similar clinical characteristics. We analyzed cerebral thrombi using histological examination, staining of complement factors, NET-markers, DNase and LL-37. In blood samples at the hyper-acute phase of stroke and 7 days later, we determined cell-free DNA, myeloperoxidase-histone complexes, DNase activity, myeloperoxidase activity, LL-37 and inflammatory cytokines. NET markers were identified in thrombi of all patients. Interestingly, the thrombus of the VITT-patient exclusively revealed complement factors and high amounts of DNase and LL-37. High DNase activity was also measured in blood, implying a disturbed NET-regulation. Furthermore, serum of the VITT-patient inhibited reactive oxygen species-dependent NET-release by phorbol-myristate-acetate to a lesser degree compared to controls, indicating either less efficient NET-inhibition or enhanced NET-induction in the blood of the VITT-patient. Additionally, the changes in specific cytokines over time were emphasized in the VITT-patient as well. In conclusion, insufficient resolution of NETs, e.g. by endogenous DNases or protection of NETs against degradation by embedded factors like the antimicrobial peptide LL-37 might thus be an important factor in the pathology of VITT besides increased NET-formation. On the basis of these findings, we discuss the potential implications of the mechanisms of disturbed NETs-degradation for diagnostic and therapeutic approaches in VITT-related thrombogenesis, other auto-immune disorders and beyond.
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Affiliation(s)
- Nicole de Buhr
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany.,Research Center for Emerging Infections and Zoonoses (RIZ), University of Veterinary Medicine Hannover, Hannover, Germany
| | - Tristan Baumann
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Leonie Fingerhut
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany.,Research Center for Emerging Infections and Zoonoses (RIZ), University of Veterinary Medicine Hannover, Hannover, Germany.,Clinic for Horses, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Rabea Imker
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany.,Research Center for Emerging Infections and Zoonoses (RIZ), University of Veterinary Medicine Hannover, Hannover, Germany
| | - Marita Meurer
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany.,Research Center for Emerging Infections and Zoonoses (RIZ), University of Veterinary Medicine Hannover, Hannover, Germany
| | - Friedrich Götz
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Paul Bronzlik
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Mark P Kühnel
- Institute of Pathology, Hannover Medical School, Hannover, Germany.,Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Danny D Jonigk
- Institute of Pathology, Hannover Medical School, Hannover, Germany.,Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Johanna Ernst
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Andrei Leotescu
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Maria M Gabriel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Hans Worthmann
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ralf Lichtinghagen
- Institute of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Maren von Köckritz-Blickwede
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany.,Research Center for Emerging Infections and Zoonoses (RIZ), University of Veterinary Medicine Hannover, Hannover, Germany
| | - Christine S Falk
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | | | - Ramona Schuppner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Gerrit M Grosse
- Department of Neurology, Hannover Medical School, Hannover, Germany
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19
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Jevtic SD, Nazy I. The COVID Complex: A Review of Platelet Activation and Immune Complexes in COVID-19. Front Immunol 2022; 13:807934. [PMID: 35371058 PMCID: PMC8965558 DOI: 10.3389/fimmu.2022.807934] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/31/2022] [Indexed: 12/11/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a highly prothrombotic viral infection that primarily manifests as an acute respiratory syndrome. However, critically ill COVID-19 patients will often develop venous thromboembolism with associated increases in morbidity and mortality. The cause for this prothrombotic state is unclear but is likely related to platelet hyperactivation. In this review, we summarize the current evidence surrounding COVID-19 thrombosis and platelet hyperactivation. We highlight the fact that several studies have identified a soluble factor in COVID-19 patient plasma that is capable of altering platelet phenotype in vitro. Furthermore, this soluble factor appears to be an immune complex, which may be composed of COVID-19 Spike protein and related antibodies. We suggest that these Spike-specific immune complexes contribute to COVID-19 platelet activation and thrombosis in a manner similar to heparin-induced thrombocytopenia. Understanding this underlying pathobiology will be critical for advancement of future research and therapeutic options.
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Affiliation(s)
- Stefan D. Jevtic
- Department of Medicine, McMaster University Medical Centre, McMaster University, Hamilton, ON, Canada
| | - Ishac Nazy
- Department of Medicine, McMaster University Medical Centre, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
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20
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Pieri M, Quaggiotti L, Fominskiy E, Landoni G, Calabrò MG, Ajello S, Bonizzoni MA, Scandroglio AM. Anticoagulation strategies in critically-ill SARS-CoV-2 patients: the role of direct thrombin inhibitors. J Cardiothorac Vasc Anesth 2022; 36:2961-2967. [PMID: 35428549 PMCID: PMC8902052 DOI: 10.1053/j.jvca.2022.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/28/2022] [Accepted: 03/04/2022] [Indexed: 11/29/2022]
Abstract
Objectives To compare heparin-based anticoagulation and bivalirudin-based anticoagulation within the context of critically ill patients with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Design An observational study. Setting At the intensive care unit of a university hospital. Participants and Interventions Critically ill patients with a SARS-CoV-2 infection receiving full anticoagulation with heparin or bivalirudin. Measurements and Main Results Twenty-three patients received full anticoagulation with bivalirudin and 60 with heparin. Despite patients in the bivalirudin group having higher mortality risk scores (SAPS II 60 ± 16 v 39 ±7, p < 0.001) and a higher need for extracorporeal support compared to the heparin group, hospital mortality was comparable (57% v 45, p = 0.3). No difference in thromboembolic complications was observed, and bleeding events were more frequent in patients treated with bivalirudin (65% v 40%, p = 0.01). Similar results were confirmed in the subgroup analysis of patients undergoing intravenous anticoagulation; in addition to comparable thrombotic complications occurrence and thrombocytopenia rate, however, no difference in the bleeding rate was observed (65% v 35%, p = 0.08). Conclusions Although heparin is the most used anticoagulant in the intensive care setting, bivalirudin-based anticoagulation was safe and effective in a cohort of critically ill patients with SARS-CoV-2. Bivalirudin may be given full consideration as an anticoagulation strategy for critically ill patients with SARS-CoV-2, especially in those with thrombocytopenia and on extracorporeal support.
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21
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Ueland T, Hausberg I, Mørtberg TV, Dahl TB, Lerum TV, Michelsen A, Ranheim T, Nezvalova Henriksen K, Dyrhol-Riise AM, Holme PA, Aaløkken TM, Skjønsberg OH, Barratt-Due A, Ahlén MT, Aukrust P, Halvorsen B. Anti-PF4/polyanion antibodies in COVID-19 patients are associated with disease severity and pulmonary pathology. Platelets 2022; 33:640-644. [DOI: 10.1080/09537104.2022.2042238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Thor Ueland
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Clinical Medicine, Thrombosis Research and Expertise Center (TREC), UiT-The Arctic University of Norway, Tromsø, Norway
| | - Ingvild Hausberg
- Norwegian National Unit for Platelet Immunology, University Hospital of North Norway, Tromsø, Norway
| | - Trude Victoria Mørtberg
- Norwegian National Unit for Platelet Immunology, University Hospital of North Norway, Tromsø, Norway
| | - Tuva Børresdatter Dahl
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway
| | - Tøri Vigeland Lerum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pulmonary Medicine, Oslo University Hospital Ullevål, Oslo, Norway
| | - Annika Michelsen
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Trine Ranheim
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Anne Ma Dyrhol-Riise
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Pål André Holme
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Trond Mogens Aaløkken
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Radiology and Nuclear Medicine, Oslo University Hospital Ullevål, Oslo, Norway
| | - Ole Henning Skjønsberg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pulmonary Medicine, Oslo University Hospital Ullevål, Oslo, Norway
| | - Andreas Barratt-Due
- Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway
- Department of Immunology, Oslo University Hospital, Oslo, Norway
| | - Maria Therese Ahlén
- Norwegian National Unit for Platelet Immunology, University Hospital of North Norway, Tromsø, Norway
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Bente Halvorsen
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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22
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Wittstock M, Walter U, Volmer E, Storch A, Weber MA, Großmann A. Cerebral venous sinus thrombosis after adenovirus-vectored COVID-19 vaccination: review of the neurological-neuroradiological procedure. Neuroradiology 2022; 64:865-874. [PMID: 35184205 PMCID: PMC8929723 DOI: 10.1007/s00234-022-02914-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/03/2022] [Indexed: 01/22/2023]
Abstract
Cerebral venous and sinus thrombosis (CVST) after adenovirus-vectored COVID-19 ChAdOx1 nCov-19 (Oxford–AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & Johnson) is a rare complication, occurring mainly in individuals under 60 years of age and more frequently in women. It manifests 4–24 days after vaccination. In most cases, antibodies against platelet factor-4/polyanion complexes play a pathogenic role, leading to thrombosis with thrombocytopenia syndrome (TTS) and sometimes a severe clinical or even fatal course. The leading symptom is headache, which usually increases in intensity over a few days. Seizures, visual disturbances, focal neurological symptoms, and signs of increased intracranial pressure are also possible. These symptoms may be combined with clinical signs of disseminated intravascular coagulation such as petechiae or gastrointestinal bleeding. If TTS-CVST is suspected, checking d-dimers, platelet count, and screening for heparin-induced thrombocytopenia (HIT-2) are diagnostically and therapeutically guiding. The imaging method of choice for diagnosis or exclusion of CVST is magnetic resonance imaging (MRI) combined with contrast-enhanced venous MR angiography (MRA). On T2*-weighted or susceptibility weighted MR sequences, the thrombus causes susceptibility artefacts (blooming), that allow for the detection even of isolated cortical vein thromboses. The diagnosis of TTS-CVST can usually be made reliably in synopsis with the clinical and laboratory findings. A close collaboration between neurologists and neuroradiologists is mandatory. TTS-CVST requires specific regimens of anticoagulation and immunomodulation therapy if thrombocytopenia and/or pathogenic antibodies to PF4/polyanion complexes are present. In this review article, the diagnostic and therapeutic steps in cases of suspected TTS associated CSVT are presented.
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Affiliation(s)
- Matthias Wittstock
- Department of Neurology, Rostock University Medical Centre, Gehlsheimer Str. 20 18147 Rostock, Germany.
| | - Uwe Walter
- Department of Neurology, Rostock University Medical Centre, Gehlsheimer Str. 20 18147 Rostock, Germany
| | - Erik Volmer
- Institute for Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, Rostock University Medical Centre, Rostock, Germany
| | - Alexander Storch
- Department of Neurology, Rostock University Medical Centre, Gehlsheimer Str. 20 18147 Rostock, Germany
| | - Marc-André Weber
- Institute for Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, Rostock University Medical Centre, Rostock, Germany
| | - Annette Großmann
- Institute for Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, Rostock University Medical Centre, Rostock, Germany
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23
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Chen C, Amelia A, Ashdown GW, Mueller I, Coussens AK, Eriksson EM. Risk surveillance and mitigation: autoantibodies as triggers and inhibitors of severe reactions to SARS-CoV-2 infection. Mol Med 2021; 27:160. [PMID: 34930107 PMCID: PMC8686808 DOI: 10.1186/s10020-021-00422-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/07/2021] [Indexed: 12/11/2022] Open
Abstract
COVID-19 clinical presentation differs considerably between individuals, ranging from asymptomatic, mild/moderate and severe disease which in some cases are fatal or result in long-term effects. Identifying immune mechanisms behind severe disease development informs screening strategies to predict who are at greater risk of developing life-threatening complications. However, to date clear prognostic indicators of individual risk of severe or long COVID remain elusive. Autoantibodies recognize a range of self-antigens and upon antigen recognition and binding, important processes involved in inflammation, pathogen defence and coagulation are modified. Recent studies report a significantly higher prevalence of autoantibodies that target immunomodulatory proteins including cytokines, chemokines, complement components, and cell surface proteins in COVID-19 patients experiencing severe disease compared to those who experience mild or asymptomatic infections. Here we discuss the diverse impacts of autoantibodies on immune processes and associations with severe COVID-19 disease.
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Affiliation(s)
- Catherine Chen
- The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, VIC, 3052, Australia
| | - Aisah Amelia
- The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, VIC, 3052, Australia
| | - George W Ashdown
- The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, VIC, 3052, Australia
| | - Ivo Mueller
- The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, VIC, 3052, Australia
| | - Anna K Coussens
- The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia.
- Department of Medical Biology, The University of Melbourne, Melbourne, VIC, 3052, Australia.
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, Wellcome Centre for Infectious Diseases Research in Africa, University of Cape, Cape Town, South Africa.
| | - Emily M Eriksson
- The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia.
- Department of Medical Biology, The University of Melbourne, Melbourne, VIC, 3052, Australia.
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24
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Root‐Bernstein R. COVID-19 coagulopathies: Human blood proteins mimic SARS-CoV-2 virus, vaccine proteins and bacterial co-infections inducing autoimmunity: Combinations of bacteria and SARS-CoV-2 synergize to induce autoantibodies targeting cardiolipin, cardiolipin-binding proteins, platelet factor 4, prothrombin, and coagulation factors. Bioessays 2021; 43:e2100158. [PMID: 34677872 PMCID: PMC8646673 DOI: 10.1002/bies.202100158] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/15/2022]
Abstract
Severe COVID-19 is often accompanied by coagulopathies such as thrombocytopenia and abnormal clotting. Rarely, such complications follow SARS-CoV-2 vaccination. The cause of these coagulopathies is unknown. It is hypothesized that coagulopathies accompanying SARS-CoV-2 infections and vaccinations result from bacterial co-infections that synergize with virus-induced autoimmunity due to antigenic mimicry of blood proteins by both bacterial and viral antigens. Coagulopathies occur mainly in severe COVID-19 characterized by bacterial co-infections with Streptococci, Staphylococci, Klebsiella, Escherichia coli, and Acinetobacter baumannii. These bacteria express unusually large numbers of antigens mimicking human blood antigens, as do both SARS-CoV-2 and adenoviruses. Bacteria mimic cardiolipin, prothrombin, albumin, and platelet factor 4 (PF4). SARS-CoV-2 mimics complement factors, Rh antigens, platelet phosphodiesterases, Factors IX and X, von Willebrand Factor (VWF), and VWF protease ADAMTS13. Adenoviruses mimic prothrombin and platelet factor 4. Bacterial prophylaxis, avoidance of vaccinating bacterially infected individuals, and antigen deletion for vaccines may reduce coagulopathy risk. Also see the video abstract here: https://youtu.be/zWDOsghrPg8.
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25
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Zyani A, Elyachioui K, Treyi C, Aabdi M, Sbai H. A rare case of intracerebral hemorrhage complicating heparin-induced thrombocytopenia in a COVID-19 patient. Ann Med Surg (Lond) 2021; 72:103070. [PMID: 34840776 PMCID: PMC8605820 DOI: 10.1016/j.amsu.2021.103070] [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: 09/27/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Heparin-induced thrombocytopenia is a rare complication of heparin therapy associated with thrombocytopenia and mainly thrombotic complications. Case report we herein describe a case of a woman hospitalized for management of a severe case of COVID-19 treated with low molecular weight heparin, who developed heparin-induced thrombocytopenia complicated by intracerebral hemorrhage with no thrombotic complications. Conclusion Discontinuation of heparin was effective without the use of other non-heparin anticoagulants, platelet transfusion or plasmapheresis. HIT is a rare complication of LMWH, it is associated with thrombocytopenia and mainly thrombotic complications. In this paper we will report a rare complication of HIT : ICH in a 63 years old woman admitted for covid 19-infection. Discontinuation of heparin was effective without the use of other non-heparin anticoagulants, platelet transfusion or plasmapheresis.
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Affiliation(s)
- A Zyani
- Anesthesiology and Intensive Care Unit, Faculty of Medicine and Pharmacy, Abdelmalek Essaadi University, Tangier, Morocco
| | - K Elyachioui
- Anesthesiology and Intensive Care Unit, Faculty of Medicine and Pharmacy, Abdelmalek Essaadi University, Tangier, Morocco
| | - C Treyi
- Anesthesiology and Intensive Care Unit, Faculty of Medicine and Pharmacy, Abdelmalek Essaadi University, Tangier, Morocco
| | - M Aabdi
- Anesthesiology and Intensive Care Unit, Faculty of Medicine and Pharmacy, Abdelmalek Essaadi University, Tangier, Morocco
| | - H Sbai
- Anesthesiology and Intensive Care Unit, Faculty of Medicine and Pharmacy, Abdelmalek Essaadi University, Tangier, Morocco
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26
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Narasimhan B, Lorente-Ros M, Aguilar-Gallardo JS, Lizardo CP, Narasimhan H, Morton C, Donahue KR, Aronow WS. Anticoagulation in COVID-19: a review of current literature and guidelines. Hosp Pract (1995) 2021; 49:307-324. [PMID: 34807786 DOI: 10.1080/21548331.2021.2007648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 infections are associated with greater risk of both arterial and venous thromboembolic events.Pathophysiology and Clinical implications: This has been attributed to a florid proinflammatory state resulting in microvascular dysfunction, activation of platelets and procoagulant systems as well as possible direct endothelial injury. The associated morbidity and mortality of these events has prompted much speculation and varied anticoagulation and fibrinolytic strategies based on multiple criteria including disease severity and biomarkers. No clear definitive benefit has been established with these approaches, which have frequently led to greater bleeding complications without significant mortality benefit.Overview: In this review, we outline the burden of these thromboembolic events in coronavirus disease-2019 (COVID-19) as well as the hypothesized contributory biological mechanisms. Finally, we provide a brief overview of the major clinical studies on the topic, and end with a summary of major societal guideline recommendations on anticoagulation in COVID-19.
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Affiliation(s)
- Bharat Narasimhan
- Debakey Cardiovascular Center, Houston Methodist Hospital-Texas Medical Center, Houston, TX, USA
| | - Marta Lorente-Ros
- Department of Medicine, Mount Sinai Morningside-West, the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jose S Aguilar-Gallardo
- Department of Medicine, Mount Sinai Morningside-West, the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Perez Lizardo
- Department of Medicine, Mount Sinai Morningside-West, the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Celia Morton
- Department of Pharmacy, Houston Methodist Hospital-Texas Medical Center, Houston, TX, USA
| | - Kevin R Donahue
- Department of Pharmacy, Houston Methodist Hospital-Texas Medical Center, Houston, TX, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
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27
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Heparin-induced thrombocytopenia in patients with COVID-19: a systematic review and meta-analysis. Blood Adv 2021; 5:4521-4534. [PMID: 34543382 PMCID: PMC8455241 DOI: 10.1182/bloodadvances.2021005314] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/07/2021] [Indexed: 12/19/2022] Open
Abstract
Heparin thromboprophylaxis is routinely administered during hospitalization for COVID-19. Because of the immune stimulation related to COVID-19, there is ongoing concern regarding a heightened incidence of heparin-induced thrombocytopenia (HIT). We performed a literature search using PubMed, EMBASE, Cochrane, and medRxiv database to identify studies that reported clinical and laboratory characteristics and/or the incidence of HIT in patients with COVID-19. The primary aim was to systematically review the clinical features and outcomes of patients with COVID-19 with confirmed HIT. The secondary objective was to perform a meta-analysis to estimate the incidence of HIT in hospitalized patients with COVID-19. A meta-analysis of 7 studies including 5849 patients revealed the pooled incidence of HIT in COVID-19 of 0.8% (95% confidence interval [CI], 0.2%-3.2%; I2 = 89%). The estimated incidences were 1.2% (95% CI, 0.3%-3.9%; I2 = 65%) vs 0.1% (95% CI, 0.0%-0.4%; I2 = 0%) in therapeutic vs prophylactic heparin subgroups, respectively. The pooled incidences of HIT were higher in critically ill patients with COVID-19 (2.2%; 95% CI, 0.6%-8.3%; I2 = 72.5%) compared with noncritically ill patients (0.1%; 95% CI, 0.0%-0.4%: I2 = 0%). There were 19 cases of confirmed HIT and 1 with autoimmune HIT for clinical and laboratory characterization. The median time from heparin initiation to HIT diagnosis was 13.5 days (interquartile range, 10.75-16.25 days). Twelve (63%) developed thromboembolism after heparin therapy. In conclusion, the incidence of HIT in patients with COVID-19 was comparable to patients without COVID-19, with higher incidences with therapeutic anticoagulation and in critically ill patients.
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28
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Othman M, Baker AT, Gupalo E, Elsebaie A, Bliss CM, Rondina MT, Lillicrap D, Parker AL. To clot or not to clot? Ad is the question-Insights on mechanisms related to vaccine-induced thrombotic thrombocytopenia. J Thromb Haemost 2021; 19:2845-2856. [PMID: 34351057 PMCID: PMC8420166 DOI: 10.1111/jth.15485] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 02/05/2023]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) has caused global concern. VITT is characterized by thrombosis and thrombocytopenia following COVID-19 vaccinations with the AstraZeneca ChAdOx1 nCov-19 and the Janssen Ad26.COV2.S vaccines. Patients present with thrombosis, severe thrombocytopenia developing 5-24 days following first dose of vaccine, with elevated D-dimer, and PF4 antibodies, signifying platelet activation. As of June 1, 2021, more than 1.93 billion COVID-19 vaccine doses had been administered worldwide. Currently, 467 VITT cases (0.000024%) have been reported across the UK, Europe, Canada, and Australia. Guidance on diagnosis and management of VITT has been reported but the pathogenic mechanism is yet to be fully elucidated. Here, we propose and discuss potential mechanisms in relation to adenovirus induction of VITT. We provide insights and clues into areas warranting investigation into the mechanistic basis of VITT, highlighting the unanswered questions. Further research is required to help solidify a pathogenic model for this condition.
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Affiliation(s)
- Maha Othman
- Department of Biomedical and Molecular SciencesSchool of MedicineQueen's UniversityKingstonOntarioCanada
- School of Baccalaureate NursingSt. Lawrence CollegeKingstonOntarioCanada
| | - Alexander T. Baker
- Center for Individualized MedicineMayo ClinicScottsdaleArizonaUSA
- Division of Cancer and GeneticsCardiff University School of MedicineCardiffUK
| | - Elena Gupalo
- National Medical Research Center for CardiologyMoscowRussia
| | - Abdelrahman Elsebaie
- Department of Biomedical and Molecular SciencesSchool of MedicineQueen's UniversityKingstonOntarioCanada
| | - Carly M. Bliss
- Division of Cancer and GeneticsCardiff University School of MedicineCardiffUK
| | - Matthew T. Rondina
- Departments of Internal Medicine and Pathology, and the Molecular Medicine ProgramUniversity of Utah HealthSalt Lake CityUtahUSA
- Department of Internal Medicine and GRECCGeorge E. Wahlen VAMCSalt Lake CityUtahUSA
| | - David Lillicrap
- Department of Pathology and Molecular MedicineQueen's UniversityKingstonOntarioCanada
| | - Alan L. Parker
- Division of Cancer and GeneticsCardiff University School of MedicineCardiffUK
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29
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Landau N, Shoenfeld Y, Negru L, Segal G. Exploring the pathways of inflammation and coagulopathy in COVID-19: A narrative tour into a viral rabbit hole. Int Rev Immunol 2021; 41:414-422. [PMID: 34678120 PMCID: PMC8544671 DOI: 10.1080/08830185.2021.1993211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 12/23/2022]
Abstract
Worldwide COVID-19 pandemic has taken a huge toll of morbidity and mortality. In selected patients, classified as severe, the overwhelming inflammatory state imposed by this infection is accompanied by a hypercoagulable state, hallmarked by a unique pattern; a marked increase in D-dimer, out of proportion to other markers of coagulopathy. In this review, we turn a spotlight to this phenomenon, offering a unified conceptual model depicting the leading hypotheses of coagulopathy in COVID-19. The key players of the coagulation cascades accompanying the COVID-19 inflammation malfunction on virtually every level; tissue factor expression is amplified, physiological anti-coagulant pathways (anti-thrombin, protein C and S, and the inhibitor of the tissue factor pathway) are impaired and fibrinolysis is inhibited. Components of autoimmunity, the complement system amongst others, further contribute to the pathology. As data continue to gather, our model offers a pathophysiological overview of COVID-19 coagulopathy, defined by the resultant histopathology: either intra-vascular or extra-vascular. We hope this review will facilitate understanding and serve as a lead point to future therapeutic directives.
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Affiliation(s)
- Nitsan Landau
- Internal Medicine “I,” Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Yehuda Shoenfeld
- The Zabludowicz Research Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
- Ariel University, Jerusalem, Israel
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
- University of the Ministry of Health of the Russian Federation (Sechenov University), Saint Petersburg, Russia
| | - Liat Negru
- Internal Medicine “I,” Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Gad Segal
- Internal Medicine “I,” Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
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30
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Hernández-Huerta MT, Pérez-Santiago AD, Pérez-Campos Mayoral L, Sánchez Navarro LM, Rodal Canales FJ, Majluf-Cruz A, Matias-Cervantes CA, Pérez-Campos Mayoral E, Romero Díaz C, Mayoral-Andrade G, Martínez Cruz M, Luna Ángel J, Pérez-Campos E. Mechanisms of Immunothrombosis by SARS-CoV-2. Biomolecules 2021; 11:1550. [PMID: 34827548 PMCID: PMC8615366 DOI: 10.3390/biom11111550] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/06/2021] [Accepted: 10/09/2021] [Indexed: 12/20/2022] Open
Abstract
SARS-CoV-2 contains certain molecules that are related to the presence of immunothrombosis. Here, we review the pathogen and damage-associated molecular patterns. We also study the imbalance of different molecules participating in immunothrombosis, such as tissue factor, factors of the contact system, histones, and the role of cells, such as endothelial cells, platelets, and neutrophil extracellular traps. Regarding the pathogenetic mechanism, we discuss clinical trials, case-control studies, comparative and translational studies, and observational studies of regulatory or inhibitory molecules, more specifically, extracellular DNA and RNA, histones, sensors for RNA and DNA, as well as heparin and heparinoids. Overall, it appears that a network of cells and molecules identified in this axis is simultaneously but differentially affecting patients at different stages of COVID-19, and this is characterized by endothelial damage, microthrombosis, and inflammation.
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Affiliation(s)
- María Teresa Hernández-Huerta
- CONACyT, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico; (M.T.H.-H.); (C.A.M.-C.)
- Grupo de Investigación Biomedicina y Salud, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico; (E.P.-C.M.); (C.R.D.); (G.M.-A.)
| | | | - Laura Pérez-Campos Mayoral
- Grupo de Investigación Biomedicina y Salud, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico; (E.P.-C.M.); (C.R.D.); (G.M.-A.)
- Centro de Investigación Facultad de Medicina UNAM-UABJO, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico;
| | | | - Francisco Javier Rodal Canales
- Centro de Investigación Facultad de Medicina UNAM-UABJO, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico;
| | | | - Carlos Alberto Matias-Cervantes
- CONACyT, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico; (M.T.H.-H.); (C.A.M.-C.)
- Grupo de Investigación Biomedicina y Salud, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico; (E.P.-C.M.); (C.R.D.); (G.M.-A.)
| | - Eduardo Pérez-Campos Mayoral
- Grupo de Investigación Biomedicina y Salud, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico; (E.P.-C.M.); (C.R.D.); (G.M.-A.)
- Centro de Investigación Facultad de Medicina UNAM-UABJO, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico;
| | - Carlos Romero Díaz
- Grupo de Investigación Biomedicina y Salud, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico; (E.P.-C.M.); (C.R.D.); (G.M.-A.)
- Centro de Investigación Facultad de Medicina UNAM-UABJO, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico;
| | - Gabriel Mayoral-Andrade
- Grupo de Investigación Biomedicina y Salud, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico; (E.P.-C.M.); (C.R.D.); (G.M.-A.)
- Centro de Investigación Facultad de Medicina UNAM-UABJO, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico;
| | - Margarito Martínez Cruz
- Tecnológico Nacional de México/IT Oaxaca, Oaxaca de Juárez, Oaxaca 68030, Mexico; (A.D.P.-S.); (M.M.C.)
| | - Judith Luna Ángel
- Hospital General Dr. Aurelio Valdivieso, Oaxaca de Juárez, Oaxaca 68000, Mexico;
| | - Eduardo Pérez-Campos
- Grupo de Investigación Biomedicina y Salud, Facultad de Medicina y Cirugía, Universidad Autónoma “Benito Juárez” de Oaxaca, Oaxaca 68020, Mexico; (E.P.-C.M.); (C.R.D.); (G.M.-A.)
- Tecnológico Nacional de México/IT Oaxaca, Oaxaca de Juárez, Oaxaca 68030, Mexico; (A.D.P.-S.); (M.M.C.)
- Laboratorio de Patología Clinica “Eduardo Pérez Ortega”, Oaxaca de Juárez, Oaxaca 68000, Mexico
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Greinacher A, Selleng K, Mayerle J, Palankar R, Wesche J, Reiche S, Aebischer A, Warkentin TE, Muenchhoff M, Hellmuth JC, Keppler OT, Duerschmied D, Lother A, Rieg S, Gawaz MP, Mueller KAL, Scheer CS, Napp M, Hahnenkamp K, Lucchese G, Vogelgesang A, Flöel A, Lovreglio P, Stufano A, Marschalek R, Thiele T. Anti-platelet factor 4 antibodies causing VITT do not cross-react with SARS-CoV-2 spike protein. Blood 2021; 138:1269-1277. [PMID: 34280256 PMCID: PMC8294553 DOI: 10.1182/blood.2021012938] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/12/2021] [Indexed: 11/21/2022] Open
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a severe adverse effect of ChAdOx1 nCoV-19 COVID-19 vaccine (Vaxzevria) and Janssen Ad26.COV2.S COVID-19 vaccine, and it is associated with unusual thrombosis. VITT is caused by anti-platelet factor 4 (PF4) antibodies activating platelets through their FcγRIIa receptors. Antibodies that activate platelets through FcγRIIa receptors have also been identified in patients with COVID-19. These findings raise concern that vaccination-induced antibodies against anti-SARS-CoV-2 spike protein cause thrombosis by cross-reacting with PF4. Immunogenic epitopes of PF4 and SARS-CoV-2 spike protein were compared using in silico prediction tools and 3D modeling. The SARS-CoV-2 spike protein and PF4 share at least 1 similar epitope. Reactivity of purified anti-PF4 antibodies from patients with VITT was tested against recombinant SARS-CoV-2 spike protein. However, none of the affinity-purified anti-PF4 antibodies from 14 patients with VITT cross-reacted with SARS-CoV-2 spike protein. Sera from 222 polymerase chain reaction-confirmed patients with COVID-19 from 5 European centers were tested by PF4-heparin enzyme-linked immunosorbent assays and PF4-dependent platelet activation assays. We found anti-PF4 antibodies in sera from 19 (8.6%) of 222 patients with COVID-19. However, only 4 showed weak to moderate platelet activation in the presence of PF4, and none of those patients developed thrombotic complications. Among 10 (4.5%) of 222 patients who had COVID-19 with thrombosis, none showed PF4-dependent platelet-activating antibodies. In conclusion, antibodies against PF4 induced by vaccination do not cross-react with the SARS-CoV-2 spike protein, indicating that the intended vaccine-induced immune response against SARS-CoV-2 spike protein is not the trigger of VITT. PF4-reactive antibodies found in patients with COVID-19 in this study were not associated with thrombotic complications.
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Affiliation(s)
- Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, Department of Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Kathleen Selleng
- Institute of Immunology and Transfusion Medicine, Department of Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital Munich, and German Centre for Infection Research (DZIF) (partner site Munich), Munich, Germany
| | - Raghavendra Palankar
- Institute of Immunology and Transfusion Medicine, Department of Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Jan Wesche
- Institute of Immunology and Transfusion Medicine, Department of Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Sven Reiche
- Department of Experimental Animal Facilities and Biorisk Management, Friedrich-Loeffler Institut, Greifswald, Germany
| | - Andrea Aebischer
- Department of Experimental Animal Facilities and Biorisk Management, Friedrich-Loeffler Institut, Greifswald, Germany
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Maximilian Muenchhoff
- Max von Pettenkofer Institute, Virology, Ludwig Maximilians University of Munich, and DZIF, Munich, Germany
| | | | - Oliver T Keppler
- Max von Pettenkofer Institute, Virology, Ludwig Maximilians University of Munich, and DZIF, Munich, Germany
| | - Daniel Duerschmied
- Heart Center Freiburg University, Cardiology and Angiology I and Medical Intensive Care, Medical Center
| | - Achim Lother
- Heart Center Freiburg University, Cardiology and Angiology I and Medical Intensive Care, Medical Center
- Institute of Experimental and Clinical Pharmacology and Toxicology, and
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Meinrad Paul Gawaz
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Karin Anne Lydia Mueller
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | | | - Matthias Napp
- Department of Anesthesiology and Intensive Care Medicine, and
| | | | - Guglielmo Lucchese
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Antje Vogelgesang
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Agnes Flöel
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Piero Lovreglio
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy; and
| | - Angela Stufano
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy; and
| | - Rolf Marschalek
- Institute of Pharmacology Biology, Biocenter, Goethe University, Frankfurt am Main, Germany
| | - Thomas Thiele
- Institute of Immunology and Transfusion Medicine, Department of Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
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Case report: cerebral sinus vein thrombosis in two patients with AstraZeneca SARS-CoV-2 vaccination. J Neurol 2021; 269:583-586. [PMID: 34609603 PMCID: PMC8491181 DOI: 10.1007/s00415-021-10731-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/14/2022]
Abstract
SARS-CoV-2 infection is associated with an increased rate of thromboembolic events and mortality. Different vaccines are globally used to limit the pandemic. In this report, we present the case of two young female patients with newly diagnosed cerebral sinus vein thrombosis occurring after injection of the vector-based ChAdOx1 vaccine. Both patients presented with unusual headache only. The two of them used an estrogen-containing contraception, had had a history of deep venous thrombosis, and both had MTHFR mutations. Both patients developed SARS-CoV-2 specific humoral and cellular immunity including both CD4 and CD8 T cells. This rare, but serious complication needs to be considered after vaccination of young females, even if there is no evidence of heparin-induced thrombocytopenia.
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The roles of platelets in COVID-19-associated coagulopathy and vaccine-induced immune thrombotic thrombocytopenia. Trends Cardiovasc Med 2021; 32:1-9. [PMID: 34455073 PMCID: PMC8390120 DOI: 10.1016/j.tcm.2021.08.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 08/06/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
In coronavirus disease 2019 (COVID-19), multiple thromboinflammatory events contribute to the pathophysiology, including coagulation system activation, suppressed fibrinolysis, vascular endothelial cell injury, and prothrombotic alterations in immune cells such as macrophages and neutrophils. Although thrombocytopenia is not an initial presentation as an infectious coagulopathy, recent studies have demonstrated the vital role of platelets in COVID-19-associated coagulopathy SARS-CoV-2 and its spike protein have been known to directly or indirectly promote release of prothrombotic and inflammatory mediators that lead to COVID-19-associated coagulopathy. Although clinical features of vaccine-induced immune thrombotic thrombocytopenia include uncommon locations of thrombosis, including cerebral venous sinus, we speculate coronavirus spike-protein-initiated prothrombotic pathways are involved in the pathogenesis of vaccine-induced immune thrombotic thrombocytopenia, as current evidence suggests that the spike protein is the promotor and other cofactors such as perturbed immune response and inflammatory reaction enhance the production of anti-platelet factor 4 antibody.
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Islam A, Bashir MS, Joyce K, Rashid H, Laher I, Elshazly S. An Update on COVID-19 Vaccine Induced Thrombotic Thrombocytopenia Syndrome and Some Management Recommendations. Molecules 2021; 26:5004. [PMID: 34443589 PMCID: PMC8400504 DOI: 10.3390/molecules26165004] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/08/2021] [Accepted: 08/13/2021] [Indexed: 12/25/2022] Open
Abstract
The thrombotic thrombocytopenia syndrome (TTS), a complication of COVID-19 vaccines, involves thrombosis (often cerebral venous sinus thrombosis) and thrombocytopenia with occasional pulmonary embolism and arterial ischemia. TTS appears to mostly affect females aged between 20 and 50 years old, with no predisposing risk factors conclusively identified so far. Cases are characterized by thrombocytopenia, higher levels of D-dimers than commonly observed in venous thromboembolic events, inexplicably low fibrinogen levels and worsening thrombosis. Hyper fibrinolysis associated with bleeding can also occur. Antibodies that bind platelet factor 4, similar to those associated with heparin-induced thrombocytopenia, have also been identified but in the absence of patient exposure to heparin treatment. A number of countries have now suspended the use of adenovirus-vectored vaccines for younger individuals. The prevailing opinion of most experts is that the risk of developing COVID-19 disease, including thrombosis, far exceeds the extremely low risk of TTS associated with highly efficacious vaccines. Mass vaccination should continue but with caution. Vaccines that are more likely to cause TTS (e.g., Vaxzevria manufactured by AstraZeneca) should be avoided in younger patients for whom an alternative vaccine is available.
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Affiliation(s)
- Amin Islam
- Department of Haematology, Mid & South Essex University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea SS0 0RY, UK; (M.S.B.); (K.J.); (S.E.)
- Department of Haematology, Queen Mary University of London, Mile End Road, London E1 3NS, UK
| | - Mohammed Sheraz Bashir
- Department of Haematology, Mid & South Essex University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea SS0 0RY, UK; (M.S.B.); (K.J.); (S.E.)
| | - Kevin Joyce
- Department of Haematology, Mid & South Essex University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea SS0 0RY, UK; (M.S.B.); (K.J.); (S.E.)
| | - Harunor Rashid
- National Centre for Immunisation Research and Surveillance(NCIRS) Kids Research, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia;
- The Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2145, Australia
| | - Ismail Laher
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Colombia, Vancouver, BC V6T 1Z3, Canada;
| | - Shereen Elshazly
- Department of Haematology, Mid & South Essex University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea SS0 0RY, UK; (M.S.B.); (K.J.); (S.E.)
- Adult Haemato-Oncology Unit, Faculty of Medicne, Ainshams University, Cairo 11566, Egypt
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[Cerebral venous sinus thrombosis after COVID-19 vaccination : Neurological and radiological management]. Radiologe 2021; 61:923-932. [PMID: 34327553 PMCID: PMC8320717 DOI: 10.1007/s00117-021-00887-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 10/27/2022]
Abstract
BACKGROUND Vaccine-induced cerebral venous and sinus thrombosis (VI-CVST) is a rare complication in recipients of the adenovirus-vectored coronavirus disease 2019 (COVID-19) vaccine ChAdOx1 nCov-19 (Vaxzevria®; AstraZeneca). OBJECTIVES Development of a diagnostic and therapeutic standard. MATERIALS AND METHODS Analysis of clinical and basic research findings, expert opinions, and experience with our own cases. RESULTS VI-CVST usually manifests on day 4-24 after vaccination, mostly in individuals aged < 60 years, and women. In the majority there is an immune pathogenesis caused by antibodies against platelet factor 4/polyanion complexes, leading to thrombotic thrombocytopenia which can result in severe, sometimes fatal, course. The cardinal symptom is headache worsening within days which, however, also can be of variable intensity. Other possible symptoms are seizures, visual disturbance, focal neurological deficits and signs of increased intracranial pressure. If VI-CVST is suspected, the determination of plasma D‑dimer level, platelet count, and screening for heparin-induced thrombocytopenia (HIT-2) are essential for treatment decision-making. Magnetic resonance imaging (MRI) with venous MR-angiography is the neuroimaging modality of choice to confirm or exclude VI-CVST. On T2* susceptibility-weighted MRI, the clot in the sinuses or veins produces marked susceptibility artifacts ("blooming"), which also enables the detection of isolated cortical venous thromboses. MRI/MR-angiography or computed tomography (CT)/CT-angiography usually allow-in combination with clinical and laboratory findings-reliable diagnosis of VI-CVST. CONCLUSIONS The clinical suspicion of VI-CVST calls for urgent laboratory and neuroimaging workup. In the presence of thrombocytopenia and/or pathogenic antibodies, specific medications for anticoagulation and immunomodulation are recommended.
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Liu T, Dai J, Yang Z, Yu X, Xu Y, Shi X, Wei D, Tang Z, Xu G, Xu W, Liu Y, Shi C, Ni Q, Yang C, Zhang X, Wang X, Chen E, Qu J. Inactivated SARS-CoV-2 vaccine does not influence the profile of prothrombotic antibody nor increase the risk of thrombosis in a prospective Chinese cohort. Sci Bull (Beijing) 2021; 66:2312-2319. [PMID: 34336365 PMCID: PMC8313791 DOI: 10.1016/j.scib.2021.07.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/09/2021] [Accepted: 07/22/2021] [Indexed: 01/06/2023]
Abstract
The presence of antiphospholipid antibodies was shown to be associated with thrombosis in coronavirus disease 2019 (COVID-19) patients. Recently, according to reports from several studies, the vaccine-induced immune thrombotic thrombocytopenia is mediated by anti-platelet factor 4 (PF4)-polyanion complex in adenovirus-vectored COVID-19 vaccine recipients. It is impendent to explore whether inactivated COVID-19 vaccine widely used in China influences prothrombotic autoantibody production and induces thrombosis. In this prospective study, we recruited 406 healthcare workers who received two doses, 21 days apart, of inactivated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine (BBIBP-CorV, Sinopharm). Paired blood samples taken before vaccination and four weeks after the second vaccination were used in detecting prothrombotic autoantibodies, including anticardiolipin (aCL), anti-β2 glycoprotein I (aβ2GP1), anti-phosphatidylserine/prothrombin (aPS/PT), and anti-PF4-heparin. The seroconversion rate of SARS-CoV-2 specific antibodies was 95.81% (389/406) four weeks after vaccination. None of the subjects had spontaneous thrombosis or thrombocytopenia over a minimum follow-up period of eight weeks. There was no significant difference in the presence of all ten autoantibodies between samples collected before and after vaccination: for aCL, IgG (7 vs. 8, P = 0.76), IgM (41 vs. 44, P = 0.73), IgA (4 vs. 4, P = 1.00); anti-β2GP1, IgG (7 vs. 6, P = 0.78), IgM (6 vs. 5, P = 0.76), IgA (3 vs. 5, P = 0.72); aPS/PT IgG (0 vs. 0, P = 1.00), IgM (6 vs. 5, P = 0.76); aPF4-heparin (2 vs. 7, P = 0.18), and antinuclear antibody (ANA) (18 vs. 21, P = 0.62). Notably, seven cases presented with anti-PF4-heparin antibodies (range: 1.18–1.79 U/mL) after vaccination, and none of them exhibited any sign of thrombotic disorder. In conclusion, inactivated SARS-CoV-2 vaccine does not influence the profile of antiphospholipid antibody and anti-PF4-heparin antibody nor increase the risk of thrombosis.
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Affiliation(s)
- Tingting Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jing Dai
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhitao Yang
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xiaoqi Yu
- Department of Infectious Diseases, Research Laboratory of Clinical Virology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yanping Xu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Shanghai Key Laboratory of Emergency Prevention, Diagnosis and Treatment of Respiratory Infectious Diseases, Shanghai 200025, China
| | - Xinming Shi
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dong Wei
- Department of Infectious Diseases, Research Laboratory of Clinical Virology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zihan Tang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Guanqun Xu
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Wenxin Xu
- Department of Infectious Diseases, Research Laboratory of Clinical Virology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yu Liu
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Ce Shi
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Qi Ni
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Chengde Yang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xinxin Zhang
- Department of Infectious Diseases, Research Laboratory of Clinical Virology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xuefeng Wang
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Erzhen Chen
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jieming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Shanghai Key Laboratory of Emergency Prevention, Diagnosis and Treatment of Respiratory Infectious Diseases, Shanghai 200025, China
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Affiliation(s)
- George Goshua
- Section of Hematology, Yale School of Medicine, New Haven, CT, USA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ayesha Butt
- Section of Hematology, Yale School of Medicine, New Haven, CT, USA
| | - Alfred I Lee
- Section of Hematology, Yale School of Medicine, New Haven, CT, USA
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Can Heparin-Coated ECMO Cannulas Induce Thrombocytopenia in COVID-19 Patients? Case Reports Immunol 2021; 2021:6624682. [PMID: 34194852 PMCID: PMC8184338 DOI: 10.1155/2021/6624682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 04/27/2021] [Accepted: 05/21/2021] [Indexed: 12/14/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is often used in the management of COVID-19-related severe respiratory failure. We report the first case of a patient with COVID-19-related ARDS on ECMO support who developed symptoms of heparin-induced thrombocytopenia (HIT) in the absence of heparin therapy. A low platelet count of 61 G/L was accompanied by the presence of circulating HIT antibodies 12 days after ECMO initiation. Replacement of the ECMO system including cannulas resulted in the normalization of the platelet count. However, the clinical situation did not improve, and the patient died 9 days later. Careful consideration of anticoagulant therapy and ECMO circuit, as well as routine HIT antibody testing, may prevent a fatal course in ECMO-supported COVID-19 patients.
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High Prevalence of Anti-PF4 Antibodies Following ChAdOx1 nCov-19 (AZD1222) Vaccination Even in the Absence of Thrombotic Events. Vaccines (Basel) 2021; 9:vaccines9070712. [PMID: 34358129 PMCID: PMC8309977 DOI: 10.3390/vaccines9070712] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 12/17/2022] Open
Abstract
It is unclear whether the ChAdOx1 nCov-19 vaccine can induce the development of anti-PF4 antibodies in vaccinated individuals who have not developed thrombosis. The aim of this prospective study was to evaluate the presence of antibodies against heparin/PF4 in adults who received a first dose of the ChAdOx1 nCov-19 vaccine, and correlate them with clinical data and antibody responses to the vaccine. We detected non-platelet activating anti-PF4 antibodies in 67% (29/43) of the vaccinated individuals on day 22 following the first dose of the ChAdOx1 nCov-19 vaccine, though these were detected in low titers. Furthermore, there was no correlation between the presence of anti-PF4 IgG antibodies and the baseline clinical characteristics of the patients. Our findings suggest that the ChAdOx1 nCov-19 vaccine can elicit anti-PF4 antibody production even in recipients without a clinical manifestation of thrombosis. The presence of anti-PF4 antibodies was not sufficient to provoke clinically evident thrombosis. Our results offer an important insight into the ongoing investigations regarding the underlying multifactorial pathophysiology of thrombotic events induced by the ChAdOx1 nCov-19 vaccine.
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Douxfils J, Favresse J, Dogné JM, Lecompte T, Susen S, Cordonnier C, Lebreton A, Gosselin R, Sié P, Pernod G, Gruel Y, Nguyen P, Vayne C, Mullier F. Hypotheses behind the very rare cases of thrombosis with thrombocytopenia syndrome after SARS-CoV-2 vaccination. Thromb Res 2021; 203:163-171. [PMID: 34029848 PMCID: PMC8123522 DOI: 10.1016/j.thromres.2021.05.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 01/17/2023]
Abstract
As of 4 April 2021, a total of 169 cases of cerebral venous sinus thrombosis (CVST) and 53 cases of splanchnic vein thrombosis were reported to EudraVigilance among around 34 million people vaccinated in the European Economic Area and United Kingdom with COVID-19 Vaccine AstraZeneca, a chimpanzee adenoviral vector (ChAdOx1) encoding the spike protein antigen of the SARS-CoV-2 virus. The first report of the European Medicines Agency gathering data on 20 million people vaccinated with Vaxzevria® in the UK and the EEA concluded that the number of post-vaccination cases with thromboembolic events as a whole reported to EudraVigilance in relation to the number of people vaccinated was lower than the estimated rate of such events in the general population. However, the EMA's Pharmacovigilance Risk Assessment Committee concluded that unusual thromboses with low blood platelets should be listed as very rare side effects of Vaxzevria®, pointing to a possible link. The same issue was identified with the COVID-19 Vaccine Janssen (Ad26.COV2.S). Currently, there is still a sharp contrast between the clinical or experimental data reported in the literature on COVID-19 and the scarcity of data on the unusual thrombotic events observed after the vaccination with these vaccines. Different hypotheses might support these observations and should trigger further in vitro and ex vivo investigations. Specialized studies were needed to fully understand the potential relationship between vaccination and possible risk factors in order to implement risk minimization strategies.
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Affiliation(s)
- Jonathan Douxfils
- University of Namur, Department of Pharmacy, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, Namur, Belgium; QUALIblood s.a., Namur, Belgium.
| | - Julien Favresse
- University of Namur, Department of Pharmacy, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, Namur, Belgium; Clinique Saint-Luc Bouge, Department of Laboratory Medicine, Bouge, Belgium
| | - Jean-Michel Dogné
- University of Namur, Department of Pharmacy, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, Namur, Belgium
| | - Thomas Lecompte
- Départements de Médecine, Hôpitaux Universitaires de Genève, service d'angiologie et d'hémostase et Faculté de Médecine, Geneva Platelet Group (GpG), Université de Genève, Geneva, Switzerland
| | - Sophie Susen
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, F-59000 Lille, France
| | - Charlotte Cordonnier
- Univ Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
| | - Aurélien Lebreton
- Service d'hématologie biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Robert Gosselin
- University of California, Davis Health System, Thrombosis and Hemostasis Center, Sacramento, United States
| | - Pierre Sié
- University Paul Sabatier, CHU of Toulouse, Laboratory of Hematology, F-31069 Toulouse, France
| | - Gilles Pernod
- CHU Grenoble Alpes, Department of Vascular Medicine, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble, France
| | - Yves Gruel
- University of Tours, EA7501 GICC, CHRU de Tours, Department of Haemostasis, Tours, France
| | | | - Caroline Vayne
- University of Tours, EA7501 GICC, CHRU de Tours, Department of Haemostasis, Tours, France
| | - François Mullier
- CHU UCL Namur, Université catholique de Louvain, Hematology Laboratory, Namur Research for Life Sciences, Namur Thrombosis and Hemostasis Center, Yvoir, Belgium
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Hocking J, Chunilal SD, Chen VM, Brighton T, Nguyen J, Tan J, Ting SB, Tran H. The first known case of vaccine-induced thrombotic thrombocytopenia in Australia. Med J Aust 2021; 215:19-20.e1. [PMID: 34117641 PMCID: PMC8447148 DOI: 10.5694/mja2.51135] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
| | | | | | - Tim Brighton
- Prince of Wales Hospital and Community Health Services, Sydney, NSW
| | | | | | | | - Huyen Tran
- Alfred Hospital, Melbourne, VIC.,Monash University, Melbourne, VIC
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42
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Affiliation(s)
- Douglas B Cines
- From the Department of Pathology and Laboratory Medicine and Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (D.B.C.); and the Department of Pediatrics, Weill Cornell Medicine, New York (J.B.B.)
| | - James B Bussel
- From the Department of Pathology and Laboratory Medicine and Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (D.B.C.); and the Department of Pediatrics, Weill Cornell Medicine, New York (J.B.B.)
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Franchini M, Liumbruno GM, Pezzo M. COVID-19 vaccine-associated immune thrombosis and thrombocytopenia (VITT): Diagnostic and therapeutic recommendations for a new syndrome. Eur J Haematol 2021; 107:173-180. [PMID: 33987882 PMCID: PMC8239516 DOI: 10.1111/ejh.13665] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/29/2022]
Abstract
Very rare cases of thrombosis associated with thrombocytopenia have occurred following the vaccination with AstraZeneca COVID‐19 vaccine. The aim of this concise review is to summarize the current knowledge on the epidemiologic and pathogenic mechanisms of this syndrome named vaccine‐associated immune thrombosis and thrombocytopenia (VITT). A practical patient management section will also be dealt with using information available from national and international scientific societies as well as expert panels. A literature search on the VITT syndrome was carried out in PubMed using appropriate MeSH headings. Overall, 40 VITT cases have been reported. Continuous pharmacovigilance monitoring is needed to collect more data on the real incidence and the pathogenesis of VITT syndrome. Such information will also help us to optimize the management this rare but often clinically severe thrombotic condition associated with COVID‐19 vaccination.
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Affiliation(s)
- Massimo Franchini
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy
| | | | - Mario Pezzo
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy
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Favaloro EJ, Henry BM, Lippi G. The complicated relationships of heparin-induced thrombocytopenia and platelet factor 4 antibodies with COVID-19. Int J Lab Hematol 2021; 43:547-558. [PMID: 34000089 PMCID: PMC8239595 DOI: 10.1111/ijlh.13582] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/20/2021] [Accepted: 04/27/2021] [Indexed: 12/20/2022]
Abstract
COVID‐19 (coronavirus disease 2019) represents a prothrombotic disorder, and there have been several reports of platelet factor 4/heparin antibodies being present in COVID‐19‐infected patients. This has thus been identified in some publications as representing a high incidence of heparin‐induced thrombocytopenia (HIT), whereas in others, findings have been tempered by general lack of functional reactivity using confirmation assays of serotonin release assay (SRA) or heparin‐induced platelet aggregation (HIPA). Moreover, in at least two publications, data are provided suggesting that antibodies can arise in heparin naïve patients or that platelet activation may not be heparin‐dependent. From this literature, we would conclude that platelet factor 4/heparin antibodies can be observed in COVID‐19‐infected patients, and they may occur at higher incidence than in historical non‐COVID‐19‐infected cohorts. However, the situation is complex, since not all platelet factor 4/heparin antibodies may lead to platelet activation, and not all identified antibodies are heparin‐dependent, such that they do not necessarily reflect “true” HIT. Most recently, a “HIT‐like” syndrome has reported in patients who have been vaccinated against COVID‐19. Accordingly, much more is yet to be learnt about the insidious disease that COVID‐19 represents, including autoimmune outcomes in affected patients.
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Affiliation(s)
- Emmanuel J Favaloro
- Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia.,School of Biomedical Sciences, Charles Sturt University, Westmead, NSW, Australia
| | - Brandon Michael Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Maltezou HC, Pavli A, Tsakris A. Post-COVID Syndrome: An Insight on Its Pathogenesis. Vaccines (Basel) 2021; 9:497. [PMID: 34066007 PMCID: PMC8151752 DOI: 10.3390/vaccines9050497] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 12/22/2022] Open
Abstract
Post-COVID syndrome is increasingly recognized as a new clinical entity in the context of SARS-CoV-2 infection. Symptoms persisting for more than three weeks after the diagnosis of COVID-19 characterize the post-COVID syndrome. Its incidence ranges from 10% to 35%, however, rates as high as 85% have been reported among patients with a history of hospitalization. Currently, there is no consensus on the classification of post-COVID syndrome. We reviewed the published information on post-COVID syndrome, putting emphasis on its pathogenesis. The pathogenesis of post-COVID syndrome is multi-factorial and more than one mechanism may be implicated in several clinical manifestations. Prolonged inflammation has a key role in its pathogenesis and may account for some neurological complications, cognitive dysfunction, and several other symptoms. A multisystem inflammatory syndrome in adults (MIS-A) of all ages has been also described recently, similarly to multisystem inflammatory syndrome in children (MIS-C). The post-infectious inflammatory pathogenetic mechanism of MIS-A is supported by the fact that its diagnosis is established through serology in up to one third of cases. Other pathogenetic mechanisms that are implicated in post-COVID syndrome include immune-mediated vascular dysfunction, thromboembolism, and nervous system dysfunction. Although the current data are indicating that the overwhelming majority of patients with post-COVID syndrome have a good prognosis, registries to actively follow them are needed in order to define the full clinical spectrum and its long-term outcome. A consensus-based classification of post-COVID syndrome is essential to guide clinical, diagnostic, and therapeutic management. Further research is also imperative to elucidate the pathogenesis of post-COVID syndrome.
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Affiliation(s)
- Helena C. Maltezou
- Directorate of Research, Studies and Documentation, National Public Health Organization, 11523 Athens, Greece
| | - Androula Pavli
- Department of Travel Medicine, National Public Health Organization, 11523 Athens, Greece;
| | - Athanasios Tsakris
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece;
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Althaus K, Zlamal J, Bakchoul T. Antibody-mediated platelet activation in COVID-19: A coincidence or a new mechanism of the dysregulated coagulation system? J Thromb Haemost 2021; 19:1171-1173. [PMID: 33880871 PMCID: PMC8250340 DOI: 10.1111/jth.15275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Karina Althaus
- Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
- Centre for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Jan Zlamal
- Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Tamam Bakchoul
- Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
- Centre for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
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Goldman M, Hermans C. Thrombotic thrombocytopenia associated with COVID-19 infection or vaccination: Possible paths to platelet factor 4 autoimmunity. PLoS Med 2021; 18:e1003648. [PMID: 34029337 PMCID: PMC8153497 DOI: 10.1371/journal.pmed.1003648] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 05/26/2021] [Indexed: 12/13/2022] Open
Abstract
Michel Goldman and Cédric Hermans discuss thrombotic mechanisms in COVID-19 and rare adverse reactions to SARS-CoV-2 vaccinations.
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Affiliation(s)
- Michel Goldman
- Institute for Interdisciplinary Innovation in Healthcare, Université libre de Bruxelles (ULB), Brussels, Belgium
| | - Cédric Hermans
- Division of Hematology, Hemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium
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Zhu W, Zheng Y, Yu M, Wei J, Zhang Y, Topchyan P, Nguyen C, Janecke R, Kreuziger LB, White GC, Hari P, Aster R, Cui W, Jobe S, Graham MB, Wang D, Wen R. SARS-CoV-2 receptor binding domain-specific antibodies activate platelets with features resembling the pathogenic antibodies in heparin-induced thrombocytopenia. RESEARCH SQUARE 2021:rs.3.rs-462080. [PMID: 34013243 PMCID: PMC8132233 DOI: 10.21203/rs.3.rs-462080/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Severe COVID-19 is associated with unprecedented thromboembolic complications. We found that hospitalized COVID-19 patients develop immunoglobulin Gs (IgGs) that recognize a complex consisting of platelet factor 4 and heparin similar to those developed in heparin-induced thrombocytopenia and thrombosis (HIT), however, independent of heparin exposure. These antibodies activate platelets in the presence of TLR9 stimuli, stimuli that are prominent in COVID-19. Strikingly, 4 out of 42 antibodies cloned from IgG1+ RBD-binding B cells could activate platelets. These antibodies possessed, in the heavy-chain complementarity-determining region 3, an RKH or Y5 motif that we recently described among platelet-activating antibodies cloned from HIT patients. RKH and Y5 motifs were prevalent among published RBD-specific antibodies, and 3 out of 6 such antibodies tested could activate platelets. Features of platelet activation by these antibodies resemble those by pathogenic HIT antibodies. B cells with an RKH or Y5 motif were robustly expanded in COVID-19 patients. Our study demonstrates that SARS-CoV-2 infection drives the development of a subset of RBD-specific antibodies that can activate platelets and have activation properties and structural features similar to those of the pathogenic HIT antibodies.
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Franchini M, Testa S, Pezzo M, Glingani C, Caruso B, Terenziani I, Pognani C, Bellometti SA, Castelli G. Cerebral venous thrombosis and thrombocytopenia post-COVID-19 vaccination. Thromb Res 2021; 202:182-183. [PMID: 33878469 PMCID: PMC8028600 DOI: 10.1016/j.thromres.2021.04.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/04/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Massimo Franchini
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy.
| | - Sophie Testa
- Hemostasis and Thrombosis Centre, Hospital of Cremona, Cremona, Italy
| | - Mario Pezzo
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy
| | - Claudia Glingani
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy
| | | | | | - Claudio Pognani
- Department of Anesthesiology and Intensive Care, Carlo Poma Hospital, Mantova, Italy
| | | | - Gianpaolo Castelli
- Department of Anesthesiology and Intensive Care, Carlo Poma Hospital, Mantova, Italy
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