An unusual presentation of acute deep vein thrombosis after the Moderna COVID-19 vaccine—a case report

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a worldwide pandemic of the multisystem disease coronavirus disease-2019 (COVID-19). Since the development of COVID-19 vaccines, there has been extensive monitoring for potential serious side effects. We report an unusual presentation of acute deep vein thrombosis (DVT) in the right upper extremity of a 27-year-old Caucasian female, 3 days after receipt of her second dose of the Moderna COVID-19 vaccine. Her relevant thrombophilia workup was negative on initial presentation. She was treated with rivaroxaban for 3 months and her symptoms of right upper extremity swelling, and pain improved. Considering our case did not have any evidence of thrombocytopenia, we discuss the possible pathophysiology of acute DVT following Moderna COVID-19 vaccine in contrast to adenoviral vector COVID-19 vaccines (ChAdOx1 nCoV-19 and Ad26.COV2.S), including mRNA COVID-19 vaccine binding to pattern recognition receptors (PRR) in the endosomes and cytosol leading to a pro inflammatory cascade and coagulopathy. We highlight the importance of initial workup for acute DVT post COVID-19 vaccination, that should include complete blood count (CBC) with platelet count, international normalized ratio (INR), prothrombin time (PTT), D-dimer levels, fibrinogen levels, platelet factor 4 (PF4)/heparin enzyme-linked immunosorbent assays (ELISA) followed by a confirmatory PF4 platelet activation assay such as serotonin release assay, P-selectin expression assay, or heparin induced platelet aggregation (HIPA) assay, and imaging for thrombosis.

No apparent association between mRNA COVID-19 vaccination and venous thromboembolism

“…Our local institutions have seen rare cases of ipsilateral upper extremity deep vein thrombosis which appear to result from local venous compression by swollen lymph nodes after vaccination or local inflammatory factors in the days following vaccination. A similar case report was found in the literature [ 55 ]. These cases of ipsilateral upper extremity DVT must be exceptionally rare such that they do not lead to a statistical increase in the number of VTE events after mRNA vaccines.…”

Unusual arm vein thrombosis after the Moderna (mRNA-1273) COVID-19 vaccination—a case report

“…According to the report of Hwang et al, rate of adverse events was lowest after mRNA-1273 vaccine, but detailed types of adverse events were not described (3). In a recent American report, their adverse reaction collecting system had at least 17 cases of acute deep vein thrombosis (DVT) after mRNA-1273 vaccine, and those are mostly detected in the lower extremities (1). There were several studies on association between COVID-19 mRNA vaccine and coagulopathy.…”

“…Among various adverse incidences related to COVID-19 infection itself or vaccination, venous thromboembolic events have been an issue. Occurrence of venous thromboembolic events after Moderna messenger ribonucleic acid (mRNA)-1273 COVID-19 seemed less common than those after mRNA vaccines of other manufacturers (1). For future study to evaluate exact association between COVID-19 vaccination and venous thromboembolism, we present one case of unusual arm vein thrombosis after mRNA-1273 COVID-19 vaccine.…”

Current Evidence in SARS-CoV-2 mRNA Vaccines and Post-Vaccination Adverse Reports: Knowns and Unknowns

“…After anticoagulant therapy, he was discharged home with supplementary oxygen [ 50 ]. DVT was also reported in the upper extremity of a 27-year-old female 3 days after the second mRNA-1273 vaccination, with a negative relevant thrombophilia workup, but she improved after three months’ rivaroxaban treatment [ 51 ]. Moreover, a 66-year-old woman developed DVT after her second BNT162b2 vaccination; initially, she manifested fever with chills, fatigue, malaise and muscle pain, and, the next day, she was admitted to hospital, unable to walk.…”