key: cord-0918406-2kpuro6x authors: Lin, Chia-Yi; Huang, Li-Yen; Wu, Kuo-An; Chan, Jenq-Shyong; Wu, Kun-Lin; Shyu, Hann-Yen; Hsiao, Po-Jen title: Abdominal pain and bilateral adrenal haemorrhage of COVID-19 vaccine-induced immune thrombotic thrombocytopenia date: 2021-09-21 journal: QJM DOI: 10.1093/qjmed/hcab239 sha: d14d327099f7af12f19beb5d6cbea3d4acbcd34b doc_id: 918406 cord_uid: 2kpuro6x nan Dear Editor, It was our pleasure to respond to the comments made by Dr Jolobe in response to our article published on 25th August in the Quarterly Journal of Medicine: An International Journal of Medicine. 1 We appreciated the letter from Dr Jolobe and would like to make a brief comment on those suggestions. Heparin-induced thrombocytopenia (HIT) caused by the use of anticoagulants or heparin is a major risk factor of adrenal haemorrhage secondary to adrenal vein thrombosis. Immune thrombotic thrombocytopenia subsequent by coronavirus disease 2019 (COVID-19) adenoviral vector-based vaccination is clinically mimics HIT. [2] [3] [4] This phenomenon is caused by the antibodies that recognize platelet factor 4 (PF4, also called CXCL4) bound to the platelets, resulting in thrombocytopenia and thrombotic events. [4] [5] [6] The common clinical presentations of bilateral adrenal haemorrhage include hypotension or shock, abdominal pain, fever, nausea and confusion. 7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 timely treatment of glucocorticoid based on the suspicion of adrenal insufficiency or crisis caused by bilateral adrenal haemorrhage should be considered in these patients. Hydrocortisone and fludrocortisone were maintained for a period of time even in some advanced cases of adrenal haemorrhage caused by VITT. 3 In our patient, the computed tomography scan of abdomen demonstrated normal without haemorrhage in both adrenal glands. Blood analysis showed both cortisol and ACTH levels were within normal ranges. In addition, COVID-19 infection may cause a hypercoagulable state and lead to the complications of adrenal vein thrombosis and haemorrhage. 9,10 During the hospital stay, we also performed a follow-up polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in our patient and the results were all negative. In conclusion, VITT can cause multiple organs involvements and devastating clinical features. Once the diagnosis of VITT is highly suspected, complete clinical examination and investigation should be taken as necessary. Early identification and appropriate management may prevent the catastrophic complications and improve patient outcomes . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 ChAdOx1 COVID-19 vaccine-induced thrombocytopenia syndrome Primary adrenal insufficiency associated with Oxford-AstraZeneca ChAdOx1 nCoV-19 vaccine-induced immune thrombotic thrombocytopenia (VITT) Vaccine-induced thrombosis and thrombocytopenia with bilateral adrenal haemorrhage Vaccine-induced immune thrombotic thrombocytopenia following AstraZeneca (ChAdOx1 nCOV19) vaccine-A case report Bilateral adrenal hemorrhage: the unrecognized cause of hemodynamic collapse associated with heparin-induced thrombocytopenia Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination Bilateral massive adrenal hemorrhage: early recognition and treatment Thrombocytopenia with acute ischemic stroke and bleeding in a patient newly vaccinated with an adenoviral vector-based COVID-19 vaccine The authors would like to thank the staff and researchers at the Taoyuan Armed Forces General Hospital, and Medical Affairs Bureau, Ministry of National Defense,