Complicated Long Term Vaccine Induced Thrombotic Immune Thrombocytopenia—A Case Report

Abstract

Background and Objectives: Vaccine induced thrombotic thrombocytopenia (VITT) may occur after COVID-19 vaccination with recombinant adenoviral vector-based vaccines. VITT can present as cerebral sinus and venous thrombosis (CSVT), often complicated by intracranial hemorrhage. Today it is unclear, how long symptomatic VITT can persist. Here, we report the complicated long-term course of a VITT patient with extremely high titers of pathogenic anti-platelet factor 4 (PF4)-IgG antibodies. Methods: Clinical and laboratory findings are presented, including the course of platelet counts, D-Dimer levels, clinical presentation, imaging, SARS-CoV-2-serological and immunological, platelet activating anti-PF4-IgG, as well as autopsy findings. Results: The patient presented with extended superior sagittal sinus thrombosis with accompanying bifrontal intracerebral hemorrhage. Repeated treatment with intravenous immune globuline (IVIG) resolved recurrent episodes of thrombocytopenia. Moreover, the patient’s serum remained strongly positive for platelet-activating anti-PF4-IgG over three months. After a period of clinical stabilization, the patient suffered a recurrent and fatal intracranial hemorrhage. Conclusions: Complicated VITT with extremely high anti-PF4-IgG titers over three months can induce recurrent thrombocytopenia despite treatment with IVIG and anticoagulation. Plasma exchange, immunoadsorption, and /or immunosuppressive treatment may be considered in complicated VITT to reduce extraordinarily high levels of anti-PF4-IgG. Long-term therapy in such cases must take the individual bleeding risk and CSVT risk into account.

Autopsy Findings and Causality Relationship between Death and COVID-19 Vaccination: A Systematic Review

“…Günther et al [25] described the case of a subject who presented with typical symptoms of VITT, including thrombocytopenia, cerebral venous and sinus thrombosis (CVST), and signs of disseminated intravascular coagulation (DIC). The presence of anti-PF4 antibodies was reported.…”

Persistence of Platelets Activation Prior to Second Doses of Covid-19 Vaccine After Vaccine-Induced Immune Thrombotic Thrombocytopenia

“… 2 However, positive platelet-activation assay at 3 months of confirmed VITT with further related complications, suggesting higher thrombosis risk, have been previously described. 3 One patient with positive platelet-activation assay before getting a second dose of Covid-19 vaccine while still receiving anticoagulation has also been reported, but no adverse events occurred. 2 Although mRNA vaccines are not associated with VITT, the physiopathology is not fully understood and, hence, it is still unclear if a second dose of Covid-19 vaccine in patients with positive platelet-activation assay is safe.…”

Pathogenesis of vaccine-induced immune thrombotic thrombocytopenia (VITT)

“…However, in a subgroup of VITT patients, persisting platelet-activating anti-PF4 antibodies [21] beyond six months have been observed [48] . Whether this persisting immune response involves B cells other than marginal zone B-cells is unresolved.…”