The use of IV immunoglobulin in the treatment of vaccine-induced immune thrombotic thrombocytopenia

Germany, 16 September 2021, Uzun et al, Blood

Summary

Five patients (3 females) with a median age of 47 years (range, 20- 57) were included in this study. The duration between vaccination and hospital admission was 7 to 9 days. All patients had severe thrombocytopenia (41.2 6 9.7 3 109 /L; range, 10-60; Figure 1AE) and increased D-dimer (9 mg/mL or higher; range, 9-54). At admission, several thrombotic events, including cerebral venous sinus thrombosis (CVST; 4 patients, cases 1-3 and 5), pulmonary embolism (2 patients, cases 4 and 5), and deep vein thrombosis (case 4), were detected. VITT diagnosis was confirmed by detecting anti-PF4 IgG antibodies in EIA (optical density [OD] 2.98 6 0.23; range, 2.07-3.36), platelet activation in the modified heparin-induced platelet aggregation assay (median time to platelet aggregation, 5 minutes; range, 5-5 minutes ), and formation of procoagulant platelets (CD62p/PS1 platelets mean: 45 6 7; range, 23-66).

All patients received parenteral anticoagulation with argatroban (n 5 4) or danaparoid (n 5 1), and 1 patient (case 5) initially received apixaban. Two patients (cases 3 and 5 on a prophylactic dose of argatroban and apixapan, respectively) developed a new thromboembolic complication at day 4 and 3 of hospitalization (before IVIG administration), respectively. Anticoagulation was continued in these patients with argatroban in a therapeutic dosage.

Individual course of the platelet counts and therapies. Five cases (A-E) of VITT after severe acute respiratory syndrome coronavirus 2 vaccination were identified. Patients were treated with nonheparin anticoagulation (argatroban, green blocks; danaparoid, lavender blocks; direct oral anticoagulants, orange blocks) combined with IVIG. Patients receiving therapeutic anticoagulation with platelet counts below 50 × 109/L (dashed line) were considered to be at enhanced risk for major hemorrhage. CSVT, cerebral sinus vein thrombosis; DVT, deep vein thrombosis; PE, pulmonary embolism; PLT, platelet.
Individual course of the platelet counts and therapies. Five cases (A-E) of VITT after severe acute respiratory syndrome coronavirus 2 vaccination were identified. Patients were treated with nonheparin anticoagulation (argatroban, green blocks; danaparoid, lavender blocks; direct oral anticoagulants, orange blocks) combined with IVIG. Patients receiving therapeutic anticoagulation with platelet counts below 50 × 109/L (dashed line) were considered to be at enhanced risk for major hemorrhage. CSVT, cerebral sinus vein thrombosis; DVT, deep vein thrombosis; PE, pulmonary embolism; PLT, platelet.

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