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Pulmonary embolism and thrombocytopenia following ChAdOx1 vaccination

2021; Elsevier BV; Volume: 397; Issue: 10287 Linguagem: Inglês

10.1016/s0140-6736(21)00871-0

1474-547X

Viktoria Muster, Thomas Gary, Reinhard B. Raggam, Albert Wölfler, Marianne Brodmann,

Venous Thromboembolism Diagnosis and Management

A 51-year-old woman attended our emergency department with a 3-day history of dyspnoea, fatigue, and cough; 11 days earlier she had the ChAdOx1 nCoV-19 vaccination. On examination she was afebrile, her peripheral oxygen saturation was 98% (fraction of inspired O2 21%), blood pressure was 150/90 mm Hg, heart rate was 98 beats per min, and body-mass index was 31 kg/m2. Laboratory investigations showed a severe thrombocytopenia of 37 × 109 platelets per L; 3 days earlier it had been 178 × 109 per L (normal 140–440). Serum concentrations of D-dimer (>34 mg/dL; normal <0·5) and C-reactive protein were increased (42 mg/L; normal 70%); the prothrombin time became unmeasurable. Plasma coagulation factor activities were normal for all other extrinsic and intrinsic coagulation factors—including von Willebrand factor. Mixing the patient's plasma in a 1:1 ratio with standard human plasma showed a deficiency of fibrinogen and factor XIII; thrombelastography confirmed the result (for details see appendix). LMWH was increased to a therapeutic dose leading to an anti-factor Xa activity of 0·5–1·0 IU/mL (therapeutic range 0·5–1·0). On day 5, the patient developed pain in the left lower back and left gluteal region; CT venography showed an increase in the thrombus in the inferior vena cava. The LMWH dose was increased to obtain supratherapeutic anti-factor Xa activity (1·0–1·5 U/mL). On the following day, the pain had reduced. Over the next 7 days, the platelet count and factor XIII activity increased; fibrinogen levels also started to increase after the platelet count reached 100 × 109 per L. 11 days after admission the platelet count was 173 × 109 per L, fibrinogen concentration was 228 mg/L, and factor XIII activity was 78% (appendix). Anticoagulation therapy was switched from LMWH to oral dabigatran 150 mg twice a day and on day 15 the patient was well and allowed home. Activation of the coagulation system producing thromboses in the context of thrombocytopenia and hypofibrinogenaemia—as occurred in our patient—is similar to heparin-induced thrombocytopenia and to that seen in critically ill COVID-19 patients (video). Contributors We were all involved in treating the patient, and drafting, reviewing, and writing the final manuscript. Written consent for publication was obtained from the patient. We declare no competing interests. Acknowledgments We are indebted to Johannes Schmid, Michael Fuchsjaeger, Manuela Aschauer, and Hannes Deutschmann, Department of Radiology, Medical University of Graz, for support with the CT and magnetic resonance images. Download .pdf (.17 MB) Help with pdf files Supplementary appendix https://www.thelancet.com/cms/asset/60effee3-cdb3-4f1e-b8dc-78bbf781bb5c/mmc2.mp4Loading ... Download .mp4 (49.42 MB) Help with .mp4 files Supplementary VideoThromboses and thrombocytopenia after ChAdOx1 nCoV-19 vaccinationClotting conundrum post COVID-19 vaccinationYoutube: https://youtu.be/LdCbU0SKKBY