A case report of vaccine-induced immune thrombocytopenia and thrombosis syndrome after Ad26.COV2.S vaccine (Janssen/Johnson & Johnson)

France, Castan et al, January 2022, Therapie

Summary

On August 2, 2021, ten days after receiving a dose of Ad26.COV2.S vaccine (Janssen/Johnson & Johnson), a 57-years-old man was admitted for left hemiplegia. The rest of clinical examination was unremarkable. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) testing by nasopharyngeal swab was negative.

He has no significant medical history and does not take any long-term treatment. Ischemic stroke, of thromboembolic origin with description of a proximal occlusion of the right internal carotid artery, was confirmed on brain magnetic resonance imaging (MRI).Initial blood tests were abnormal, including thrombocytopenia at 27 G/L, hepatic cytolysis at 10N and biological disseminated intravascular coagulation (DIC) with fibrinogen < 1 g/L, D-dimer> 128,000 ng/mL and fibrin degradation products (FDPs) > 150 μg/mL. Myelogram was normal.

Arterial Doppler ultrasound of the supra-aortic trunks confirmed a complete thrombosis of the right internal carotid artery. Ultrasound and abdomino-pelvic CT scan revealed partial portal vein thrombosis and right and middle hepatic vein thrombosis. Pain in the left leg prompted the realization of a venous Doppler ultrasound of the lower limbs, finding a distal deep venous thrombosis. Transthoracic echocardiography was normal.Patient received intravenous acetylsalicylic acid (250 mg/24 h) and subcutaneous enoxaparin (100 IU/kg/12 h) and was admitted to the intensive care unit.

Neurological examination showed cognitive disorders, hemiparesis of the left upper limb rated at 1/5 and hemiparesis of the left lower limb side at 2/5, with signs of spatial neglect. Because of neurological worsening (appearance of a left homonymous hemianopsia at 48 hours), brain CT scan showed intracranial bleeding leading to stop antithrombotic agent and curative anticoagulation.VITT syndrome was suspected. Differential diagnostics were ruled out (SARS-CoV-2 infection, others infections, immune thrombocytopenic purpura (ITP), drugs, hypersplenism, genetic disorder, cancer, trauma, surgery, immobilization, thrombotic thrombocytopenic purpura (TTP), thrombophilia).Search for anti-PF4 antibodies and a platelet aggregation test were performed, from which only anti-PF4 antibodies returned positive at 1,181 IU/L (N < 0.5) by ELISA method (Zymutest HIA IgGAM Hyphen), platelet aggregation test returned normal.The patient received corticosteroids 0,75 mg/kg and intravenous immunoglobulins at 2 g/kg over 2 days, either seven days after the onset of symptoms. Biological parameters improved over the next few days, in particular platelets (Fig. 1 ) and fibrinogen which returned to normal values in 5 days and liver function tests in 17 days. On day 10, internal carotid artery was re-permeabilized on arterial Doppler ultrasound, and thrombus completely disappeared on the control a month and a half later.

Concomitantly, neurological symptoms began to improve, including hemiplegia, cognitive and ophthalmologic disorders. Follow-up brain scan did not show any new intracranial bleeding. Preventive anticoagulation by subcutaneous enoxaparin 4000 IU/24 h was reinitiated, followed by subcutaneous tinzaparin 175 IU/kg/24 h and later by Apixaban 5 mg/12 h, once the liver function is normal.Seven days after initiation of treatment, neurological examination improved, with hemiparesis of the left upper limb rated at 3/5 and hemiparesis of the left lower limb rated at 4/5.

Four months after the onset of symptoms, patient can walk a short distance with a cane.

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