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Warkentin TE, Baskin-Miller J, Moll S. More on Adenovirus-Associated Thrombocytopenia, Thrombosis, and VITT-like Antibodies. Reply. N Engl J Med 2023; 389:1729-1731. [PMID: 37913523 DOI: 10.1056/nejmc2310644] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Affiliation(s)
| | | | - Stephan Moll
- University of North Carolina School of Medicine, Chapel Hill, NC
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2
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Skornova I, Simurda T, Stanciakova L, Lauko V, Holly P, Samos M, Bolek T, Schnierer M, Drotarova M, Belakova KM, Sokol J, Stasko J, Mokan M, Gumulec J, Chrastinova L. A Functional Assay for the Determination of Heparin-Induced Thrombocytopenia via Flow Cytometry. Diagnostics (Basel) 2023; 13:3019. [PMID: 37761386 PMCID: PMC10527925 DOI: 10.3390/diagnostics13183019] [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: 06/27/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening complication of heparin therapy (both unfractionated heparin and low-molecular-weight heparin). In our study, we examined a group of 122 patients with suspected HIT. The samples of all patients were analyzed in the first step using an immunoassay (ID-PaGIA Heparin/PF4, Hemos1L-Acustar HIT IgG, ZYMUTEST HIA Monostrip IgG) to detect the presence of antibodies against heparin-PF4 complexes (platelet factor 4). When the immunoassay was positive, the sample was subsequently analyzed for HIT with a functional flow cytometry assay, the HITAlert kit, the purpose of which was to demonstrate the ability of the antibodies present to activate platelets. A diagnosis of HIT can be made only after a positive functional test result. In this article, we present an overview of our practical experience with the use of the new functional method of analysis, HIT, with flow cytometry. In this work, we compared the mutual sensitivity of two functional tests, SRA and the flow cytometry HITAlert kit, in patients perceived as being at risk for HIT. This work aims to delineate the principle, procedure, advantages, pitfalls, and possibilities of the application of the functional test HITAlert using flow cytometry.
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Affiliation(s)
- Ingrid Skornova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Tomas Simurda
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Lucia Stanciakova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Viliam Lauko
- National Institute of Cardiovascular Diseases, 83348 Bratislava, Slovakia
| | - Pavol Holly
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Matej Samos
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia; (M.S.); (T.B.); (M.M.)
| | - Tomas Bolek
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia; (M.S.); (T.B.); (M.M.)
| | - Martin Schnierer
- Department of Gastroenterology Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia;
| | - Miroslava Drotarova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Kristina Maria Belakova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Juraj Sokol
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Jan Stasko
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Marian Mokan
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia; (M.S.); (T.B.); (M.M.)
| | - Jaroslav Gumulec
- Clinic of Hemato-Oncology, Faculty Hospital in Ostrava, 708 00 Ostrava, Czech Republic;
| | - Leona Chrastinova
- Institute of Hematology and Blood Transfusion in Prague, 128 20 Nove Mesto, Czech Republic;
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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: 9] [Impact Index Per Article: 4.5] [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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Detection of Platelet-Activating Antibodies Associated with Vaccine-Induced Thrombotic Thrombocytopenia by Flow Cytometry: An Italian Experience. Viruses 2022; 14:v14061133. [PMID: 35746602 PMCID: PMC9228627 DOI: 10.3390/v14061133] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/16/2022] [Accepted: 05/21/2022] [Indexed: 11/22/2022] Open
Abstract
Rare cases of thrombocytopenia and thrombosis after anti-COVID-19 adenovirus-associated mRNA vaccines (VITT) due to platelet-activating anti-platelet-factor 4 (PF4)/polyanion antibodies have been reported. VITT laboratory diagnosis, similarly to heparin-induced thrombocytopenia (HIT) diagnosis, requires immunoassays for anti-PF4/polyanion antibodies identification, such as ELISA assays and platelet-activating functional tests, such as heparin-induced platelet activation test (HIPA), to confirm their pathogenicity. We compared the flow cytometry (FC) measurement of platelet p-selectin exposure to the gold standard functional test HIPA for diagnosis confirmation in 13 patients with a clinical VITT syndrome (6M/7F; median age 56 (33–78)) who resulted positive to anti-PF4/polyanion antibodies ELISA assays (12/13). FC and HIPA similarly identified three different patterns: (1) a typical non-heparin-dependent VITT pattern (seven and six patients by FC and HIPA, respectively); (2) low/no platelet activation in patients under IvIg therapy (five out of five and two out of four patients by FC and HIPA, respectively); (3) a HIT pattern. Antibodies investigated by FC became negative after 7, 17, and 24 days of therapy in three patients. FC measurement of P-selectin exposure was as sensitive as HIPA but simpler to detect anti-PF4/polyanion antibodies in VITT patients. FC could reliably discriminate VITT from HIT, thus helping for the choice of the anticoagulant.
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Antibodies against Platelet Factor 4 and Their Associated Pathologies: From HIT/HITT to Spontaneous HIT-Like Syndrome, to COVID-19, to VITT/TTS. Antibodies (Basel) 2022; 11:antib11010007. [PMID: 35225866 PMCID: PMC8883896 DOI: 10.3390/antib11010007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/20/2021] [Accepted: 01/19/2022] [Indexed: 02/06/2023] Open
Abstract
Antibodies against platelet factor 4 (PF4), a protein released from alpha-granules of activated platelets, may cause a number of pathophysiological conditions. The most commonly known is heparin-induced thrombocytopenia (HIT), which develops in a small proportion of people treated with the anticoagulant drug heparin. Notably, PF4 binds with high affinity to heparin, and in HIT, complexes of PF4/H may, in a small proportion of susceptible patients, trigger the development of anti-PF4 antibodies and subsequent platelet activation and aggregation, ultimately leading to the development of pathological thrombosis at sites of vessel occlusion. Of more modern interest, antibodies against PF4 may also arise in patients with COVID-19 (Coronavirus Disease 2019) or in patients who have been vaccinated against COVID-19, especially in recipients of adenovirus-based vaccines. For this latter group of patients, the terms VITT (vaccine-induced [immune] thrombotic thrombocytopenia) and TTS (thrombotic thrombocytopenia syndrome) have been coined. Another category associated with this pathophysiology comprises those in whom a precipitating event is not clear; this category is referred to as ‘spontaneous HIT-like syndrome’. Despite its name, it arises as an HIT-mimicking disorder but without antecedent heparin exposure. In this narrative review, we describe the development of antibodies against PF4, and associated pathophysiology, in such conditions.
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Amiral J. Editorial for the Special Issue of Monitoring Anticoagulants. Biomedicines 2022; 10:biomedicines10010155. [PMID: 35052834 PMCID: PMC8773630 DOI: 10.3390/biomedicines10010155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
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Elalamy I, Gerotziafas G, Alamowitch S, Laroche JP, Van Dreden P, Ageno W, Beyer-Westendorf J, Cohen AT, Jimenez D, Brenner B, Middeldorp S, Cacoub P. SARS-CoV-2 Vaccine and Thrombosis: An Expert Consensus on Vaccine-Induced Immune Thrombotic Thrombocytopenia. Thromb Haemost 2021; 121:982-991. [PMID: 33946120 PMCID: PMC8322589 DOI: 10.1055/a-1499-0119] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/03/2021] [Indexed: 12/30/2022]
Abstract
Historically, the vaccination strategies developed in the second half of the 20th century have facilitated the eradication of infectious diseases. From the onset of COVID-19 pandemic to the end of April 2021, more than 150 million cases and 3 million deaths were documented worldwide with disruption of the economic and social activity, and with devastating material, physical, and psychological consequences. Reports of unusual and severe thrombotic events, including cerebral and splanchnic venous thrombosis and other autoimmune adverse reactions, such as immune thrombocytopenia or thrombotic microangiopathies in connection with some of the SARS-CoV-2 vaccines, have caused a great deal of concern within the population and the medical community. This report is intended to provide practical answers following an overview of our knowledge on these thrombotic events that are extremely rare but have serious consequences. Vaccine hesitancy threatens to reverse the progress made in controlling vaccine-preventable diseases. These adverse events must be put into perspective with an objective analysis of the facts and the issues of the vaccination strategy during this SARS-CoV-2 pandemic. Health care professionals remain the most pertinent advisors and influencers regarding vaccination decisions; they have to be supported to provide reliable and credible information on vaccines. We need to inform, reassure, and support our patients when the prescription is made. Facing these challenges and observations, a panel of experts express their insights and propose a tracking algorithm for vaccinated patients based on a 10-point guideline for decision-making on what to do and not to do.
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Affiliation(s)
- Ismail Elalamy
- Hematology and Thrombosis Center, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Sorbonne Université, Paris, France
- Research Group “Cancer, Haemostasis and Angiogenesis,” INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Grigoris Gerotziafas
- Hematology and Thrombosis Center, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Sorbonne Université, Paris, France
- Research Group “Cancer, Haemostasis and Angiogenesis,” INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
| | - Sonia Alamowitch
- AP-HP, Service des Urgences cérébro-vasculaires, Hôpital Pitié-Salpétrière, Paris, France
- Centre de recherche de Saint Antoine, INSERM, UMRS 938, Sorbonne Université Paris, France
| | - Jean-Pierre Laroche
- Service de médecine vasculaire, hôpital Saint-Éloi, CHU de Montpellier, Montpellier cedex 5, France
- Médipôle, 1139, chemin du Lavarin, Avignon, France
| | - Patrick Van Dreden
- Research Group “Cancer, Haemostasis and Angiogenesis,” INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
| | - Walter Ageno
- Department of Emergency Medicine and Thrombosis Center, Ospedale di Circolo and Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Jan Beyer-Westendorf
- Department of Medicine I, Division of Haematology and Haemostaseology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Alexander T. Cohen
- Department of Haematological Medicine, Guys and St Thomas' NHS Foundation Trust, King's College London, London, United Kingdom
| | - David Jimenez
- Respiratory Department, Ramon y Cajal Hospital (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Benjamin Brenner
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut National de la Santé et de la Recherche Médicale, INSERM, Paris, France
- CNRS, FRE3632, Paris, France
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Université, UPMC Univ Paris 06, Paris, France
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