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Pelzl L, Uzun G, Marini I, Zlamal J, Trumpp PN, Karakuyu A, Bakchoul T, Althaus K. Heparin-activated procoagulant platelet assay: a flow cytometry-based functional test for heparin-induced thrombocytopenia. J Thromb Haemost 2024; 22:470-479. [PMID: 37838242 DOI: 10.1016/j.jtha.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/04/2023] [Accepted: 10/05/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Functional platelet activation assays are required for the diagnosis of heparin-induced thrombocytopenia (HIT). Due to their sophisticated methodology, they are only available in reference centers. OBJECTIVES To evaluate the diagnostic accuracy of the flow cytometry-based heparin-activated procoagulant platelet (HAPP) assay in the laboratory diagnosis of HIT. METHODS Procoagulant platelets (PCP), defined by the expression of phosphatidylserine and CD62-P, were evaluated by flow cytometry in platelet-rich plasma from healthy donors after incubation with patient sera in the absence and presence of heparin. A sample was considered positive in HAPP assay, if the following 3 criteria were met: 1) the percentage of PCPs was ≥10.3% after incubation with 0.2 IU/mL heparin, 2) the fold increase in presence of 0.2 IU/mL heparin compared with buffer was ≥1.5, and 3) 100 IU/mL of heparin resulted in ≥50% inhibition of PCP. HAPP assay was validated in a prospective cohort (n = 202) of consecutive specimens submitted to our laboratory for serologic diagnosis of HIT. Heparin-induced platelet activation (HIPA) assay was used as the reference standard. RESULTS HIT-positive sera induced PCPs in the presence of 0.2 IU/mL heparin, which was inhibited with 100 IU/mL of heparin. In the prospective validation cohort, there were 15 HIPA+ and 187 HIPA- sera. HAPP was positive in 20 samples in this cohort. Using optimized cut-offs, HAPP assay had a sensitivity of 93.3% and specificity of 96.8%. CONCLUSION HAPP assay is promising as a simple and reliable functional assay for HIT; however, further studies are needed to confirm our results in larger cohorts.
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Affiliation(s)
- Lisann Pelzl
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Günalp Uzun
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Irene Marini
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Jan Zlamal
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Pascal N Trumpp
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Aleyna Karakuyu
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany.
| | - Karina Althaus
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
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2
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Jesudas R, Takemoto CM. Where have all the platelets gone? HIT, DIC, or something else? Hematology Am Soc Hematol Educ Program 2023; 2023:43-50. [PMID: 38066886 PMCID: PMC10727081 DOI: 10.1182/hematology.2023000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Thrombocytopenia in ill children is common; accurately diagnosing the underlying etiology is challenging and essential for appropriate management. Triggers for accelerated consumption of platelets are numerous; common downstream mechanisms of clearance include platelet trapping in microvascular thrombi, phagocytosis, and platelet activation. Thrombocytopenia with microangiopathic hemolytic anemia (MAHA) is frequently due to disseminated intravascular coagulation. Thrombotic microangiopathy (TMA) is a subgroup of MAHA. Specific TMA syndromes include thrombotic thrombocytopenic purpura, complement-mediated TMA (CM-TMA), and Shiga toxin-mediated hemolytic uremic syndrome. Isolated thrombocytopenia is characteristic of immune thrombocytopenia; however, concomitant cytopenias are frequent in critically ill patients, making the diagnosis difficult. Immune thrombocytopenia with large vessel thrombosis is a feature of heparin-induced thrombocytopenia and antiphospholipid antibody syndrome. In addition, thrombocytopenia is common with macrophage activation, which is characteristic of hemophagocytic lymphohistiocytosis. While thrombocytopenia in ill patients can be driven by hypoproliferative processes such as myelosuppression and/or bone marrow failure, this review will focus on consumptive thrombocytopenia due to immune and nonimmune causes.
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3
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Spurgeon BEJ, Frelinger AL. OMIP-097: High-parameter phenotyping of human platelets by spectral flow cytometry. Cytometry A 2023; 103:935-940. [PMID: 37786346 DOI: 10.1002/cyto.a.24797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/24/2023] [Accepted: 09/12/2023] [Indexed: 10/04/2023]
Abstract
Using spectral flow cytometry, we developed a 16-color panel for analysis of platelet phenotype and function in human whole blood. The panel contains markers of clinical relevance and follows an optimized protocol for the high-parameter phenotyping of (phosphatidylserine positive) procoagulant platelets. Inclusion of established markers, such as CD62P and PAC-1, allows the subsetting of classic (proinflammatory and proaggregatory) phenotypes, while addition of novel markers, such as TLR9, allows the resolution of platelets with nonclassic functions. Multiple inducible (C3b, CD63, CD107a, CD154, and TLT-1) and constitutive (CD29, CD31, CD32, CD36, CD42a, CD61, and GPVI) markers are also measurable, and we demonstrate the use of automatic gating for platelet analysis. The panel is widely applicable to research and clinical settings and can be readily modified, should users wish to tailor the panel to more specific needs.
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Affiliation(s)
- Benjamin E J Spurgeon
- Center for Platelet Research Studies, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew L Frelinger
- Center for Platelet Research Studies, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
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4
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Man L, Yount K, Grazioli A, Padmanabhan A, Thiele R, Maitland HS, Mazzeffi M. Recrudescent Heparin-Induced Thrombocytopenia After Therapeutic Plasma Exchange in a Patient Undergoing Thoracic Aortic Replacement. J Cardiothorac Vasc Anesth 2023; 37:2592-2596. [PMID: 37827918 PMCID: PMC10802261 DOI: 10.1053/j.jvca.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/31/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Louise Man
- University of Virginia School of Medicine, Department of Medicine, Division of Hematology and Oncology, Charlottesville, VA
| | - Kenan Yount
- University of Virginia School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Charlottesville, VA
| | | | - Anand Padmanabhan
- Mayo Clinic College of Medicine, Department of Pathology, Rochester, MN
| | - Robert Thiele
- University of Virginia, Department of Anesthesiology, Charlottesville, VA
| | - Hillary S Maitland
- University of Virginia School of Medicine, Department of Medicine, Division of Hematology and Oncology, Charlottesville, VA
| | - Michael Mazzeffi
- University of Virginia, Department of Anesthesiology, Charlottesville, VA.
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5
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Kanack AJ, Athale J, Leger RR, Saadalla A, Heikal NM, Chen D, Garcia DA, Singh R, Pruthi RK, Padmanabhan A. "Autoimmune HIT" antibodies in diagnostic samples are a potential artifact and not associated with more severe outcomes. Blood Adv 2023; 7:4431-4434. [PMID: 37267446 PMCID: PMC10440464 DOI: 10.1182/bloodadvances.2023009811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/04/2023] Open
Affiliation(s)
- Adam J. Kanack
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Janhavi Athale
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ
| | - Rachel R. Leger
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Abdul Saadalla
- Department of Pathology, University of Utah, Salt Lake City, UT
| | - Nahla M. Heikal
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Dong Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - David A. Garcia
- Department of Medicine, University of Washington, Seattle, WA
| | - Ravinder Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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6
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May J, Westbrook B, Cuker A. Heparin-induced thrombocytopenia: An illustrated review. Res Pract Thromb Haemost 2023; 7:100283. [PMID: 37601013 PMCID: PMC10439402 DOI: 10.1016/j.rpth.2023.100283] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse drug effect from unfractionated or low-molecular-weight heparin that results in thrombocytopenia and potentially catastrophic thrombosis. HIT occurs due to the development of platelet-activating antibodies against multimolecular complexes of platelet factor 4 and heparin. Given the frequency of thrombocytopenia and heparin use among hospitalized patients, calculation of the 4Ts Score is recommended to identify patients at increased likelihood of HIT and direct further evaluation. In patients with an intermediate or high probability 4Ts Score, an immunoassay and functional assay are recommended to confirm or refute the diagnosis of HIT. Heparin avoidance and initiation of nonheparin anticoagulation are the mainstays of acute HIT management. In this illustrated review, we provide visual summaries of the diagnosis and management of HIT, highlighting connections between pathophysiology and clinical care as well as summarizing efforts in quality improvement in the field. We further emphasize common pitfalls and pearls in diagnosis and management to encourage evidence-based care. We include graphical representation of the unique challenges of HIT with cardiopulmonary bypass and also delineate autoimmune HIT and its subtypes.
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Affiliation(s)
- Jori May
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brian Westbrook
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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7
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Zhu W, Zheng Y, Yu M, Wu Y, Wei J, Zhou L, Fu G, Schneider N, Jones C, Irani M, Padmanabhan A, Aster R, Wang D, Wen R. Cloned antibodies from patients with HIT provide new clues to HIT pathogenesis. Blood 2023; 141:1060-1069. [PMID: 36493339 PMCID: PMC10023725 DOI: 10.1182/blood.2022017612] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/01/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction characterized by antibodies that recognize platelet factor 4/heparin complexes (PF4/H) and activate platelets to create a prothrombotic state. Although a high percentage of heparin-treated patients produce antibodies to PF4/H, only a subset also makes antibodies that are platelet activating (PA). A close correlation between PA antibodies and the likelihood of experiencing HIT has been demonstrated in clinical studies, but how PA (presumptively pathogenic) and nonactivating (NA) (presumptively benign) antibodies differ from each other at the molecular level is unknown. To address this issue, we cloned 7 PA and 47 NA PF4/H-binding antibodies from 6 patients with HIT and characterized their structural and functional properties. Findings showed that PA clones differed significantly from NA clones in possessing 1 of 2 heavy chain complementarity-determining region 3 (HCDR3) motifs, RX1-2R/KX1-2R/H (RKH) and YYYYY (Y5), in an unusually long complementarity-determining region 3 (≥20 residues). Mutagenic studies showed that modification of either motif in PA clones reduced or abolished their PA activity and that appropriate amino acid substitutions in HCDR3 of NA clones can cause them to become PA. Repertoire sequencing showed that the frequency of peripheral blood IgG+ B cells possessing RKH or Y5 was significantly higher in patients with HIT than in patients without HIT given heparin, indicating expansion of B cells possessing RKH or Y5 in HIT. These findings imply that antibodies possessing RKH or Y5 are relevant to HIT pathogenesis and suggest new approaches to diagnosis and treatment of this condition.
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Affiliation(s)
- Wen Zhu
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Mei Yu
- Versiti Blood Research Institute, Milwaukee, WI
| | - Yaling Wu
- Versiti Blood Research Institute, Milwaukee, WI
- Biomedical Research Center of South China, College of Life Sciences, Fujian Normal University, Fuzhou, Fujian, China
| | - Jianhui Wei
- Versiti Blood Research Institute, Milwaukee, WI
- Biomedical Research Center of South China, College of Life Sciences, Fujian Normal University, Fuzhou, Fujian, China
| | - Lu Zhou
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI
| | - Guoping Fu
- Versiti Blood Research Institute, Milwaukee, WI
| | | | | | - Mehraboon Irani
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | - Anand Padmanabhan
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN
| | - Richard Aster
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Demin Wang
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI
| | - Renren Wen
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI
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8
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Schultz NH, Søraas AVL, Sørvoll IH, Akkök ÇA, Vetlesen A, Bhamra JS, Ahlen MT, Holme PA, Aamodt AH, Skagen K, Skattør TH, Skjelland M, Wiedmann MK. Vaccine associated benign headache and cutaneous hemorrhage after ChAdOx1 nCoV-19 vaccine: A cohort study. J Stroke Cerebrovasc Dis 2023; 32:106860. [PMID: 36403363 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106860] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Fatal complications have occurred after vaccination with ChAdOx1 nCoV-19, a vaccine against Covid-19. Vaccine-induced immune thrombotic thrombocytopenia (VITT) with severe outcome is characterized by venous thrombosis, predominantly in cerebral veins, thrombocytopenia and anti-PF4/polyanion antibodies. Prolonged headaches and cutaneous hemorrhages, frequently observed after the ChAdOx1 nCoV-19 vaccine, have therefore caused anxiety among vaccinees. We investigated whether these symptoms represent a mild form of VITT, with a potential for aggravation, e.g. in case of a second vaccination dose, or a different entity of vaccine complications MATERIALS AND METHODS: We included previously healthy individuals who had a combination of headache and spontaneous severe cutaneous hemorrhages emerging after the 1st dose of the ChAdOx1 nCoV-19 vaccine. Twelve individuals were found to meet the inclusion criteria, and a phone interview, cerebral MRI, assessment of platelet counts, anti PF4/polyanion antibodies and other laboratory tests were performed. RESULTS None of the symptomatic vaccinees had cerebral vein thrombosis, hemorrhage or other pathology on MRI. Platelet counts were within normal range and no anti-PF4/polyanion platelet activating antibodies were found. Moreover, vasculitis markers, platelet activation markers and thrombin generation were normal. Furthermore, almost all symptoms resolved, and none had recurrence of symptoms after further vaccination with mRNA vaccines against Covid-19. CONCLUSIONS The combination of headaches and subcutaneous hemorrhage did not represent VITT and no other specific coagulation disorder or intracranial pathology was found. However, symptoms initially mimicking VITT demand vigilance and low threshold for a clinical evaluation combined with platelet counts and D-dimer.
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9
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Kanack AJ, Jones CG, Singh B, Leger RR, Splinter NP, Heikal NM, Pruthi RK, Chen D, George G, Abou-Ismail MY, Wool GD, Gundabolu K, Padmanabhan A. Off-the-shelf cryopreserved platelets for the detection of HIT and VITT antibodies. Blood 2022; 140:2722-2729. [PMID: 35998675 PMCID: PMC9837435 DOI: 10.1182/blood.2022017283] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/27/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is suspected much more often than it is confirmed. Technically simple platelet factor 4 (PF4)-polyanion enzyme-linked immunosorbent assays (ELISAs) are sensitive but nonspecific. In contrast, accurate functional tests such as the serotonin release assay, heparin-induced platelet activation assay, and PF4-dependent P-selectin expression assay require fresh platelets and have complex assay end points, limiting their availability to specialized reference laboratories. To enable broad deployment of functional testing, we sought to extend platelet viability significantly by optimizing storage conditions and developed a simple functional assay end point by measuring the release of a platelet α-granule protein, thrombospondin-1 (TSP1), in an ELISA format. Platelet cryopreservation conditions were optimized by freezing platelets at controlled cooling rates that preserve activatability. Several-month-old cryopreserved platelets were treated with PF4 or heparin and were evaluated for their ability to be activated by HIT and vaccine-induced immune thrombotic thrombocytopenia (VITT) antibodies in the TSP1 release assay (TRA). HIT and spontaneous HIT patient samples induced significantly higher TSP1 release using both PF4-treated (PF4-TRA) and heparin-treated cryopreserved platelets relative to samples from patients suspected of HIT who lacked platelet-activating antibodies. This latter group included several patients that tested strongly positive in PF4-polyanion ELISA but were not platelet-activating. Four VITT patient samples tested in the TRA activated PF4-treated, but not heparin-treated, cryopreserved platelets, consistent with recent data suggesting the requirement for PF4-treated platelets for VITT antibody detection. These findings have the potential to transform the testing paradigm in HIT and VITT, making decentralized, technically simple functional testing available for rapid and accurate in-hospital diagnosis.
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Affiliation(s)
- Adam J. Kanack
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Bandana Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Noah P. Splinter
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Nahla M. Heikal
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Dong Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Gemlyn George
- Department of Medicine, University of Colorado, Aurora, CO
| | | | | | - Krishna Gundabolu
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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10
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Kanack A, Lægreid IJ, Johansen S, Reikvam H, Ahlen MT, Padmanabhan A. Human papilloma virus vaccine and VITT antibody induction. Am J Hematol 2022; 97:E363-E364. [PMID: 35834243 PMCID: PMC9463111 DOI: 10.1002/ajh.26659] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Adam Kanack
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ingvild J Lægreid
- The Norwegian National Unit for Platelet Immunology, University Hospital of North Norway, Tromso, Norway
| | - Silje Johansen
- Section of Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Håkon Reikvam
- Section of Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Maria T Ahlen
- The Norwegian National Unit for Platelet Immunology, University Hospital of North Norway, Tromso, Norway
| | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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11
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Kanack AJ, Padmanabhan A. Vaccine-induced immune thrombotic thrombocytopenia. Best Pract Res Clin Haematol 2022; 35:101381. [PMID: 36494147 PMCID: PMC9467921 DOI: 10.1016/j.beha.2022.101381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/02/2022] [Accepted: 09/02/2022] [Indexed: 12/14/2022]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is primarily a complication of adenoviral vector-based covid-19 vaccination. In VITT, thrombocytopenia and thrombosis mediated by anti-platelet factor 4 (PF4) antibodies can be severe, often characterized by thrombosis at unusual sites such as the cerebral venous sinus and splanchnic circulation. Like in heparin-induced thrombocytopenia (HIT) and spontaneous HIT, VITT antibodies recognize PF4-polyanion complexes and activate PF4-treated platelets but additionally bind to un-complexed PF4, a critical finding that could be leveraged for more specific detection of VITT. Intravenous immunoglobulin and non-heparin-based anticoagulation remain the mainstay of treatment. Second dose/boosters of mRNA covid-19 vaccines appear safe in patients with adenoviral vector-associated VITT. Emerging data is consistent with the possibility that ultra-rare cases of VITT may be seen in the setting of mRNA and virus-like particle (VLP) technology-based vaccinations and until more data is available, it is prudent to consider VITT in the differential diagnosis of all post-vaccine thrombosis and thrombocytopenia reactions.
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Affiliation(s)
- Adam J Kanack
- Division of Experimental Pathology, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, United States.
| | - Anand Padmanabhan
- Divisions of Hematopathology, Transfusion Medicine & Experimental Pathology, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, United States.
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12
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Padmanabhan A, Kanack AJ, Kaplan RB, Sangli S. COVID-19 mRNA-1273 vaccine induces production of vaccine-induced immune thrombotic thrombocytopenia antibodies. Am J Hematol 2022; 97:E223-E225. [PMID: 35312193 PMCID: PMC9081112 DOI: 10.1002/ajh.26542] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Anand Padmanabhan
- Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota USA
| | - Adam J. Kanack
- Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota USA
| | - Robert B. Kaplan
- Department of Hematology and Cellular Therapy Allegheny Health Network Pittsburgh Pennsylvania USA
| | - Swathi Sangli
- Department of Pulmonary and Critical Care Allegheny Health Network Pittsburgh Pennsylvania USA
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13
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Tchen S, Bhatt R, Rezazadeh A, Foy P. Using novel PF4-dependent P-selectin expression assay to diagnose heparin-induced thrombocytopaenia postliver transplantation. BMJ Case Rep 2022; 15:15/6/e248269. [DOI: 10.1136/bcr-2021-248269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Heparin-induced thrombocytopaenia (HIT) is a well-known adverse event associated with the use of heparin products. HIT may be difficult to diagnose in patients following liver transplantation as patients routinely require massive transfusion support and immunosuppression. As an alternative or adjunctive to the serotonin release assay, the PF4-dependent P-selectin expression assay (PEA) may be a useful diagnostic test in the determination of HIT in this patient population. In this case, we describe a 63-year-old man who had an orthotopic liver transplant that was complicated by HIT that was diagnosed using the PEA.
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14
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Kanack AJ, Singh B, George G, Gundabolu K, Koepsell SA, Abou‐Ismail MY, Moser KA, Smock KJ, Green D, Major A, Chan CW, Wool GD, Reding M, Ashrani AA, Bayas A, Grill DE, Padmanabhan A. Persistence of Ad26.COV2.S-associated vaccine-induced immune thrombotic thrombocytopenia (VITT) and specific detection of VITT antibodies. Am J Hematol 2022; 97:519-526. [PMID: 35132672 PMCID: PMC8986571 DOI: 10.1002/ajh.26488] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 12/22/2022]
Abstract
Rare cases of COVID‐19 vaccinated individuals develop anti‐platelet factor 4 (PF4) antibodies that cause thrombocytopenia and thrombotic complications, a syndrome referred to as vaccine‐induced immune thrombotic thrombocytopenia (VITT). Currently, information on the characteristics and persistence of anti‐PF4 antibodies that cause VITT after Ad26.COV2.S vaccination is limited, and available diagnostic assays fail to differentiate Ad26.COV2.S and ChAdOx1 nCoV‐19‐associated VITT from similar clinical disorders, namely heparin‐induced thrombocytopenia (HIT) and spontaneous HIT. Here we demonstrate that while Ad26.COV2.S‐associated VITT patients are uniformly strongly positive in PF4‐polyanion enzyme‐linked immunosorbent assays (ELISAs); they are frequently negative in the serotonin release assay (SRA). The PF4‐dependent p‐selectin expression assay (PEA) that uses platelets treated with PF4 rather than heparin consistently diagnosed Ad26.COV2.S‐associated VITT. Most Ad26.COV2.S‐associated VITT antibodies persisted for >5 months in PF4‐polyanion ELISAs, while the PEA became negative earlier. Two patients had otherwise unexplained mild persistent thrombocytopenia (140‐150 x 103/µL) 6 months after acute presentation. From an epidemiological perspective, differentiating VITT from spontaneous HIT, another entity that develops in the absence of proximate heparin exposure, and HIT is important, but currently available PF4‐polyanion ELISAs and functional assay are non‐specific and detect all three conditions. Here, we report that a novel un‐complexed PF4 ELISA specifically differentiates VITT, secondary to both Ad26.COV2.S and ChAdOx1 nCoV‐19, from both spontaneous HIT, HIT and commonly‐encountered HIT‐suspected patients who are PF4/polyanion ELISA‐positive but negative in functional assays. In summary, Ad26.COV2.S‐associated VITT antibodies are persistent, and the un‐complexed PF4 ELISA appears to be both sensitive and specific for VITT diagnosis.
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Affiliation(s)
- Adam J. Kanack
- Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota USA
| | - Bandana Singh
- Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota USA
| | - Gemlyn George
- Department of Medicine University of Colorado Aurora Colorado USA
| | - Krishna Gundabolu
- Department of Internal Medicine University of Nebraska Medical Center Omaha Nebraska USA
| | - Scott A. Koepsell
- Department of Pathology and Microbiology University of Nebraska Medical Center Omaha Nebraska USA
| | | | - Karen A. Moser
- Department of Pathology University of Utah Health Sciences Center and ARUP Institute for Clinical and Experimental Pathology Salt Lake City Utah USA
| | - Kristi J. Smock
- Department of Pathology University of Utah Health Sciences Center and ARUP Institute for Clinical and Experimental Pathology Salt Lake City Utah USA
| | - David Green
- Department of Medicine NYU Langone Health New York New York USA
| | - Ajay Major
- Department of Medicine University of Chicago Chicago Illinois USA
| | - Clarence W. Chan
- Department of Pathology University of Chicago Chicago Illinois USA
| | - Geoffrey D. Wool
- Department of Pathology University of Chicago Chicago Illinois USA
| | - Mark Reding
- Department of Medicine University of Minnesota Medical Center Minneapolis Minnesota USA
| | | | - Antonios Bayas
- Department of Neurology and Clinical Neurophysiology University Hospital of Augsburg Augsburg Germany
| | - Diane E. Grill
- Department of Health Sciences Research Mayo Clinic Rochester Minnesota USA
| | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology Mayo Clinic Rochester Minnesota USA
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15
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Abou-Ismail MY, Kanack A, Splinter N, Smock KJ, Moser K, Padmanabhan A. Safety of BNT162b2 mRNA vaccine booster in the setting of Ad26.COV2.S-associated VITT. Blood Adv 2022:bloodadvances. [PMID: 35468623 DOI: 10.1182/bloodadvances.2022007753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/20/2022] [Indexed: 11/20/2022] Open
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16
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Johansen S, Laegreid IJ, Ernstsen SL, Azrakhsh NA, Kittang AO, Lindås R, Gjertsen BT, Vetti N, Mørtberg TV, Sørvoll IH, Holme PA, Ahlen MT, Reikvam H. Thrombosis and thrombocytopenia after HPV vaccination. J Thromb Haemost 2022; 20:700-704. [PMID: 34817130 PMCID: PMC9906134 DOI: 10.1111/jth.15604] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/11/2021] [Accepted: 11/18/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Vaccine-induced immune thrombotic thrombocytopenia (VITT) has so far only been reported after adenovirus vector severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines. OBJECTIVE We report findings in a 25-year-old woman who presented with thrombocytopenia, venous thrombosis, elevated D-dimer levels, and high levels of platelet-activating antibodies to platelet factor 4-polyanion complexes 10 days after Gardasil 9 vaccination for human papillomavirus (HPV). The patient exhibited clinical and laboratory features in line with the recently defined VITT syndrome, described after adenoviral vector vaccination to prevent coronavirus disease 2019. CONCLUSION We report a case of VITT following HPV vaccination. This should raise awareness of the possibility of VITT also occurring after other vaccines, not exclusively adenoviral vector-based SARS-CoV-2 vaccines.
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Affiliation(s)
- Silje Johansen
- Section of Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ingvild Jenssen Laegreid
- The Norwegian National Unit for Platelet Immunology, Division of Diagnostics, University Hospital of North Norway, Tromsø, Norway
| | - Siw Leiknes Ernstsen
- The Norwegian National Unit for Platelet Immunology, Division of Diagnostics, University Hospital of North Norway, Tromsø, Norway
| | - Nessar Ahmad Azrakhsh
- Section of Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Astrid Olsnes Kittang
- Section of Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Roald Lindås
- Section of Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Bjørn Tore Gjertsen
- Section of Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Nils Vetti
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Medical Science, University of Bergen, Bergen, Norway
| | - Trude Victoria Mørtberg
- The Norwegian National Unit for Platelet Immunology, Division of Diagnostics, University Hospital of North Norway, Tromsø, Norway
- Institute of Medical Biology, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Ingvild Hausberg Sørvoll
- The Norwegian National Unit for Platelet Immunology, Division of Diagnostics, University Hospital of North Norway, Tromsø, Norway
| | - Pål André Holme
- Department of Hematology, Oslo University Hospital, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
| | - Maria Therese Ahlen
- The Norwegian National Unit for Platelet Immunology, Division of Diagnostics, University Hospital of North Norway, Tromsø, Norway
| | - Håkon Reikvam
- Section of Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
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Pouplard C, Rollin J, Vayne C, Charuel N, Ahmadi Z, Alberio L, Azjenberg N, Althaus K, Bakchoul T, Chong B, Curtis BR, Faille D, Gomez FJ, Gresele P, Morel-Kopp MC, Mullier F, Nazy I, Smith JW, Greinacher A, Gruel Y. Multicentre evaluation of 5B9, a monoclonal anti-PF4/heparin IgG mimicking human HIT antibodies, as an internal quality control in HIT functional assays: Communication from the ISTH SSC Subcommittee on Platelet Immunology. J Thromb Haemost 2022; 20:252-259. [PMID: 34657390 DOI: 10.1111/jth.15560] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Functional tests for the diagnosis of heparin-induced thrombocytopenia (HIT) exhibit variable performance. OBJECTIVES We evaluated in a multicenter study whether 5B9, a monoclonal anti-PF4/heparin IgG mimicking human HIT antibodies, could be used as an internal quality control. METHODS 5B9 was sent to 11 laboratories in seven countries, and six initial concentrations ranging from 10 to 400 μg/mL were tested by heparin-induced platelet activation assay (HIPA), serotonin release assay (SRA), platelet aggregation test (PAT), flow cytometry (FC), or heparin-induced multiple-electrode aggregometry (HIMEA). Each method was evaluated in three different laboratories using experimental procedures identical to those usually applied for the diagnosis of HIT by testing platelets from 10 different healthy donors. RESULTS The procedures used varied among the laboratories, particularly when platelet-rich plasma and whole blood were used. Nevertheless, positive results were obtained with at least 100 μg/ml of 5B9 for most donors tested by all centers (except one) performing HIPA, SRA, or HIMEA. FC and PAT results were more heterogeneous. FC results from one center that used washed platelets preincubated with PF4 were positive with all donors at 50 µg/ml 5B9, but at least 200 μg/ml of 5B9 were required to activate cells with most donors tested using PAT. CONCLUSION This study confirms that HIT functional tests are not well standardized and exhibit variable sensitivity for the detection of platelet-activating antibodies. However, 5B9 is a potentially useful tool to standardize functional tests, to select responding platelet donors, and consequently to improve the performance of these assays and comparability between laboratories.
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Affiliation(s)
- Claire Pouplard
- University of Tours, EA7501 GICC, CHRU de Tours, Department of Haemostasis, Tours, France
| | - Jérôme Rollin
- 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
| | - Noémie Charuel
- University of Tours, EA7501 GICC, CHRU de Tours, Department of Haemostasis, Tours, France
| | - Zohra Ahmadi
- Haematology Research Unit, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Nadine Azjenberg
- University of Paris, INSERM U1148 LVTS, Department of Hematology, AP-HP, Bichat-Claude Bernard Hospital, Paris, France
| | - Karina Althaus
- Transfusion Medicine, Medical Faculty of Tubingen, University of Tubingen, Tubingen, Germany
| | - Tamam Bakchoul
- Transfusion Medicine, Medical Faculty of Tubingen, University of Tubingen, Tubingen, Germany
| | - Beng Chong
- Haematology Research Unit, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Brian R Curtis
- Blood Research Institute, Versiti, Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
| | - Dorothée Faille
- University of Paris, INSERM U1148 LVTS, Department of Hematology, AP-HP, Bichat-Claude Bernard Hospital, Paris, France
| | - Francisco-Javier Gomez
- Service and Central Laboratory of Hematology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Paolo Gresele
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Marie-Christine Morel-Kopp
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, and Northern Blood Research Centre, Kolling Institute, The University of Sydney, Sydney, NSW, Australia
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Hematology Laboratory, Namur Research for Life Sciences, Yvoir, Belgium
| | - Izhac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, Hamilton, ON, Canada
| | - James W Smith
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Andreas Greinacher
- Institut fuer Immunologie und Transfusionsmedizin, Universitaetsmedizin Greifswald, Greifswald, Germany
| | - Yves Gruel
- University of Tours, EA7501 GICC, CHRU de Tours, Department of Haemostasis, Tours, France
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18
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Arora K, Rodgers S, Alkhatib Y, Onwubiko IN, Padmanabhan A, Otrock ZK. P-selectin expression assay in a repeatedly serotonin-release assay-negative patient with heparin-induced thrombocytopenia. Blood Coagul Fibrinolysis 2021; 32:522-525. [PMID: 34261860 DOI: 10.1097/mbc.0000000000001062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune complication of heparin therapy caused by antibodies to complexes of platelet factor 4 (PF4) and heparin. Pathogenic antibodies to PF4/heparin bind and activate platelets to propagate a hypercoagulable state culminating in life-threatening thrombosis. The serotonin-release assay (SRA) is considered the gold-standard test to diagnose HIT. However, the sensitivity of the SRA was questioned with reported cases of clinical diagnosis of HIT and negative SRA. Herein, we present the utility of platelet factor 4-dependent P-selectin expression assay (PEA) in diagnosing HIT in a patient with thrombocytopenia and recurrent thrombosis who repeatedly tested negative with SRA.
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Affiliation(s)
| | | | - Yaser Alkhatib
- Division of Hematology and Oncology, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | | | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Zaher K Otrock
- Department of Pathology and Laboratory Medicine
- Department of Pathology, Wayne State University School of Medicine, Detroit, Michigan, USA
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19
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Singh B, Kanack A, Bayas A, George G, Abou-Ismail MY, Kohlhagen M, Christ M, Naumann M, Moser K, Smock K, Grazioli A, Murray D, Padmanabhan A. Anti-PF4 VITT antibodies are oligoclonal and variably inhibited by heparin. medRxiv 2021. [PMID: 34611669 PMCID: PMC8491860 DOI: 10.1101/2021.09.23.21263047] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background COVID-19 vaccines have been associated with a rare thrombotic and thrombocytopenic reaction, Vaccine-induced immune thrombotic thrombocytopenia (VITT) characterized by platelet-activating anti-PF4 antibodies. This study sought to assess clonality of VITT antibodies and evaluate their characteristics in antigen-based and functional platelet studies. Methods Anti-PF4 antibodies were isolated from five patients with VITT secondary to ChAdOx1 nCoV-19 (n=1) or Ad26.COV2.S (n=4) vaccination. For comparative studies with heparin-induced thrombocytopenia (HIT), anti-PF4 antibodies were isolated from one patient with spontaneous HIT, another with “classical” HIT, and two patients with non-pathogenic (non-platelet activating) anti-PF4 antibodies. Isolated antibodies were subject to ELISA and functional testing, and mass spectrometric evaluation for clonality determination. Results All five VITT patients had oligoclonal anti-PF4 antibodies (3 monoclonal, one bi- and one tri-clonal antibodies), while HIT anti-PF4 antibodies were polyclonal. Notably, like VITT antibodies, anti-PF4 antibodies from a spontaneous HIT patient were monoclonal. The techniques employed did not detect non-pathogenic anti-PF4 antibodies. The ChAdOx1 nCoV-19-associated VITT patient made an excellent recovery with heparin treatment. In vitro studies demonstrated strong inhibition of VITT antibody-induced platelet activation with therapeutic concentrations of heparin in this and one Ad26.COV2.S-associated VITT patient. Oligoclonal VITT antibodies with persistent platelet-activating potential were detected at 6 and 10 weeks after acute presentation in two patients tested. Two of the 5 VITT patients had recurrence of thrombocytopenia and one patient had focal seizures several weeks after acute presentation. Conclusion Oligoclonal anti-PF4 antibodies mediate VITT. Heparin use in VITT needs to be further studied.
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20
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Pishko AM, Cuker A. Diagnosing heparin-induced thrombocytopenia: The need for accuracy and speed. Int J Lab Hematol 2021; 43 Suppl 1:96-102. [PMID: 34288442 DOI: 10.1111/ijlh.13564] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/06/2021] [Accepted: 04/14/2021] [Indexed: 01/15/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic condition resulting from pathogenic antibodies to complexes of heparin and platelet factor 4 (PF4). The diagnosis of HIT can be challenging due to the widespread use of heparin and the frequency of thrombocytopenia in hospitalized patients. Laboratory testing for HIT typically includes an immunoassay to detect antibodies to PF4-heparin and a functional assay. Current HIT diagnostic algorithms recommend using the 4Ts score to determine the need for HIT laboratory testing. Automated calculation of HIT clinical prediction scores in the electronic health record may improve the identification of patients who should undergo HIT testing. Another challenge in the management of patients with suspected HIT is the turnaround time of the laboratory testing needed to confirm the diagnosis. Due to the high daily thrombotic risk of HIT, clinicians must treat patients with intermediate to high pretest likelihood of HIT empirically while awaiting the test results. Treatment for HIT often involves alternative anticoagulants that lack reversal agents, which may increase bleeding risk, prolong hospital stays, and increase costs for patients suspected of having HIT. Rapid immunoassays hold promise to improve the speed of HIT diagnosis. These assays must retain a very high sensitivity for this "can't miss" diagnosis, yet have sufficient specificity to be of diagnostic value. A Bayesian approach has been proposed using two rapid immunoassays in succession, which decreased analytic turnaround time to 60 minutes. Such an approach has the potential to be a much-needed clinical advance in improving accuracy and speed in the diagnosis of HIT.
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Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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21
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22
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Lundstrom K, Barh D, Uhal BD, Takayama K, Aljabali AAA, Abd El-Aziz TM, Lal A, Redwan EM, Adadi P, Chauhan G, Sherchan SP, Azad GK, Rezaei N, Serrano-Aroca Á, Bazan NG, Hassan SS, Panda PK, Pal Choudhury P, Pizzol D, Kandimalla R, Baetas-da-Cruz W, Mishra YK, Palu G, Brufsky AM, Tambuwala MM, Uversky VN. COVID-19 Vaccines and Thrombosis-Roadblock or Dead-End Street? Biomolecules 2021; 11:1020. [PMID: 34356644 PMCID: PMC8301964 DOI: 10.3390/biom11071020] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 12/16/2022] Open
Abstract
Two adenovirus-based vaccines, ChAdOx1 nCoV-19 and Ad26.COV2.S, and two mRNA-based vaccines, BNT162b2 and mRNA.1273, have been approved by the European Medicines Agency (EMA), and are invaluable in preventing and reducing the incidence of coronavirus disease-2019 (COVID-19). Recent reports have pointed to thrombosis with associated thrombocytopenia as an adverse effect occurring at a low frequency in some individuals after vaccination. The causes of such events may be related to SARS-CoV-2 spike protein interactions with different C-type lectin receptors, heparan sulfate proteoglycans (HSPGs) and the CD147 receptor, or to different soluble splice variants of the spike protein, adenovirus vector interactions with the CD46 receptor or platelet factor 4 antibodies. Similar findings have been reported for several viral diseases after vaccine administration. In addition, immunological mechanisms elicited by viral vectors related to cellular delivery could play a relevant role in individuals with certain genetic backgrounds. Although rare, the potential COVID-19 vaccine-induced immune thrombotic thrombocytopenia (VITT) requires immediate validation, especially in risk groups, such as the elderly, chronic smokers, and individuals with pre-existing incidences of thrombocytopenia; and if necessary, a reformulation of existing vaccines.
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Affiliation(s)
| | - Debmalya Barh
- Centre for Genomics and Applied Gene Technology, Institute of Integrative Omics and Applied Biotechnology (IIOAB), Purba Medinipur 721172, India
- Departamento de Genética, Ecologia e Evolução, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Bruce D. Uhal
- Department of Physiology, Michigan State University, East Lansing, MI 48824, USA;
| | - Kazuo Takayama
- Center for iPS Cell Research and Application, Kyoto University, Kyoto 606-8397, Japan;
| | - Alaa A. A. Aljabali
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Yarmouk University, P.O. Box 566, Irbid 21163, Jordan;
| | - Tarek Mohamed Abd El-Aziz
- Zoology Department, Faculty of Science, Minia University, El-Minia 61519, Egypt;
- Department of Cellular and Integrative Physiology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55902, USA;
| | - Elrashdy M. Redwan
- Biological Science Department, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
| | - Parise Adadi
- Department of Food Science, University of Otago, Dunedin 9054, New Zealand;
| | - Gaurav Chauhan
- School of Engineering and Sciences, Tecnológico de Monterrey, Av. Eugenio Garza Sada 2501 Sur, Monterrey 64849, Mexico;
| | - Samendra P. Sherchan
- Department of Environmental Health Sciences, Tulane University, New Orleans, LA 70112, USA;
| | | | - Nima Rezaei
- Research Center for Immunodeficiency, Children’s Medical Center, Tehran University of Medical Sciences, Tehran 1416753955, Iran;
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), 17177 Stockholm, Sweden
| | - Ángel Serrano-Aroca
- Biomaterials and Bioengineering Lab, Centro de Investigación Traslacional San Alberto Magno, Universidad Católica de Valencia San Vicente Mártir, c/Guillem de Castro 94, 46001 Valencia, Spain;
| | - Nicolas G. Bazan
- Neuroscience Center of Excellence, School of Medicine, LSU Health New Orleans, New Orleans, LA 70112, USA;
| | - Sk Sarif Hassan
- Department of Mathematics, Pingla Thana Mahavidyalaya, Maligram 721140, India;
| | - Pritam Kumar Panda
- Condensed Matter Theory Group, Materials Theory Division, Department of Physics and Astronomy, Uppsala University, Box 516, 75120 Uppsala, Sweden;
| | | | - Damiano Pizzol
- Italian Agency for Development Cooperation—Khartoum, Sudan Street 33, Al Amarat 11111, Sudan;
| | - Ramesh Kandimalla
- Applied Biology, CSIR-Indian Institute of Technology, Uppal Road, Tarnaka, Hyderabad 500007, India;
- Department of Biochemistry, Kakatiya Medical College, Warangal 506007, India
| | - Wagner Baetas-da-Cruz
- Translational Laboratory in Molecular Physiology, Centre for Experimental Surgery, College of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-901, Brazil;
| | - Yogendra Kumar Mishra
- Mads Clausen Institute, University of Southern Denmark, NanoSYD, Alsion 2, 6400 Sønderborg, Denmark;
| | - Giorgio Palu
- Department of Molecular Medicine, University of Padova, 35122 Padova, PD, Italy;
| | - Adam M. Brufsky
- UPMC Hillman Cancer Center, Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA;
| | - Murtaza M. Tambuwala
- School of Pharmacy and Pharmaceutical Science, Ulster University, Coleraine BT52 1SA, UK
| | - Vladimir N. Uversky
- Department of Molecular Medicine and USF Health Byrd Alzheimer’s Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
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Abstract
BACKGROUND Several cases of unusual thrombotic events and thrombocytopenia have developed after vaccination with the recombinant adenoviral vector encoding the spike protein antigen of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (ChAdOx1 nCov-19, AstraZeneca). More data were needed on the pathogenesis of this unusual clotting disorder. METHODS We assessed the clinical and laboratory features of 11 patients in Germany and Austria in whom thrombosis or thrombocytopenia had developed after vaccination with ChAdOx1 nCov-19. We used a standard enzyme-linked immunosorbent assay to detect platelet factor 4 (PF4)-heparin antibodies and a modified (PF4-enhanced) platelet-activation test to detect platelet-activating antibodies under various reaction conditions. Included in this testing were samples from patients who had blood samples referred for investigation of vaccine-associated thrombotic events, with 28 testing positive on a screening PF4-heparin immunoassay. RESULTS Of the 11 original patients, 9 were women, with a median age of 36 years (range, 22 to 49). Beginning 5 to 16 days after vaccination, the patients presented with one or more thrombotic events, with the exception of 1 patient, who presented with fatal intracranial hemorrhage. Of the patients with one or more thrombotic events, 9 had cerebral venous thrombosis, 3 had splanchnic-vein thrombosis, 3 had pulmonary embolism, and 4 had other thromboses; of these patients, 6 died. Five patients had disseminated intravascular coagulation. None of the patients had received heparin before symptom onset. All 28 patients who tested positive for antibodies against PF4-heparin tested positive on the platelet-activation assay in the presence of PF4 independent of heparin. Platelet activation was inhibited by high levels of heparin, Fc receptor-blocking monoclonal antibody, and immune globulin (10 mg per milliliter). Additional studies with PF4 or PF4-heparin affinity purified antibodies in 2 patients confirmed PF4-dependent platelet activation. CONCLUSIONS Vaccination with ChAdOx1 nCov-19 can result in the rare development of immune thrombotic thrombocytopenia mediated by platelet-activating antibodies against PF4, which clinically mimics autoimmune heparin-induced thrombocytopenia. (Funded by the German Research Foundation.).
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Affiliation(s)
- Andreas Greinacher
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Thomas Thiele
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Theodore E Warkentin
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Karin Weisser
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Paul A Kyrle
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Sabine Eichinger
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
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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. Res Sq 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
Heparin-induced thrombocytopenia is an immune-mediated disorder caused by antibodies that recognize complexes of platelet factor 4 and heparin. Thrombosis is a central and unpredictable feature of this syndrome. Despite optimal management, disease morbidity and mortality from thrombosis remain high. The hypercoagulable state in heparin-induced thrombocytopenia is biologically distinct from other thrombophilic disorders in that clinical complications are directly attributable to circulating ultra-large immune complexes. In some individuals, ultra-large immune complexes elicit unchecked cellular procoagulant responses that culminate in thrombosis. To date, the clinical and biologic risk factors associated with thrombotic risk in heparin-induced thrombocytopenia remain elusive. This review will summarize our current understanding of thrombosis in heparin-induced thrombocytopenia with attention to its clinical features, cellular mechanisms, and its management.
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Affiliation(s)
| | - Anand Padmanabhan
- Divisions of Hematopathology, Transfusion Medicine, and Experimental Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (A.P.)
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