key: cord-1012495-67wh600q
authors: Akuna, Melanie; Qureshi, Moeez; Miller, Nathan
title: VITT REACTION ASSOCIATED WITH JOHNSON & JOHNSON COVID-19 VACCINE
date: 2021-10-31
journal: Chest
DOI: 10.1016/j.chest.2021.07.764
sha: bb9bfcc11f3b26640861234ce91ffb0040bc3cbe
doc_id: 1012495
cord_uid: 67wh600q

nan

A 59-year-old caucasian woman with past medical history significant for coronary artery disease, hypertension, COPD, and tobacco use. She initially presented to Urgent Care with a complaint of 5 days of progressive left leg swelling with associated pain and erythema. No recent illness, immobility, or injury. She was transferred to the hospital Emergency Department for evaluation of suspected DVT. Venous doppler of the left leg performed in the emergency department found extensive occlusive DVT of the left superficial femoral, popliteal, posterior tibial, and peroneal veins. Initial labs were significant for thrombocytopenia with a platelet count of 15 x10E3/uL, INR of 1.3 with low fibrinogen and high fibrin degradation products, and elevated LDH of 704 U/L. Unable to treat her DVT with anticoagulation, an IVC filter was placed and she was admitted to medicine. Early the next morning the patient began experiencing loss of sensation in the right foot. Arterial doppler of the right leg significant for high-grade occlusion of the right proximal superficial femoral artery. She was again emergently taken to the cath lab where abdominal aortogram showed occlusions of bilateral iliac and superficial femoral arteries. Bilateral thrombectomy and stents were placed in both iliac arteries. Hematology was consulted for what appeared to be HITT reaction despite no heparin exposure and treatment with Bivalirudin was initiated. With more detailed history, it was discovered that the patient had recovered from an uneventful COVID-19 infection in January and recently had Johnson & Johnson COVID-19 vaccine administered just 10 days prior to symptom onset. A report was filed to the Vaccine Adverse Event Reporting System (VAERS). Peripheral blood smear noted thrombocytopenia with normocytic anemia, but no schistocytes were seen. HIT panel was positive HIT antigen on PF4 and positive SRA, with an OD of 0.519. No further clot formation occurred during her stay and platelet count improved after initiation of bivalirudin.

Recently the Johnson & Johnson COVID-19 vaccine was placed on hold in the U.S. for investigation of 6 cases of serious VITT reactions in women [3], confirmed with positive PF4 heparin antibodies without any heparin exposure, as was the case with our patient. Spontaneous HIT (or VITT) with positive PF4 antibodies despite no known heparin exposure is thought to be due to cross-reactivity from similar polyanions [2].

CONCLUSIONS: Considering VITT for thrombocytopenia and thrombosis within 2 weeks after COVID-19 vaccination may be beneficial in earlier treatment with bivalirudin to prevent further vascular occlusions.

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