ABSTRACT
Summary: Vaccine-induced thrombosis and thrombocytopenia (VITT) after vaccination against SARS-CoV-2 with the adenoviral vector-based vaccines ChAdOx1 and Ad26.COV2.S has been associated with adrenal pathology, such as bilateral adrenal vein thrombosis, adrenal cortex haemorrhage and adrenal insufficiency in 6% of patients. We report the case of a 23-year-old woman who presented at 8 days after ChAdOx1 vaccination with a low platelet count of 43 × 109/L, raised d dimers >100 000 ng/mL and multiple lobar and segmental pulmonary emboli. Anti-platelet factor 4 antibodies were detected confirming definite VITT in accordance with the UK diagneostic criteria. At 16 days post-vaccine, further imaging showed bilateral adrenal haemorrhage, non-occlusive splenic vein thrombosis and right ventricular thrombosis. Her cortisol level was <25 nmol/L. She was treated with anticoagulation, plasmapheresis, immunosuppression and steroid replacement. She had high anti-spike titre and positive anti-nucleocapsid titres for SARS-CoV-2. She developed seizures secondary to posterior reversible encephalopathy, requiring intensive care. After 4 weeks in hospital, she was discharged on warfarin, hydrocortisone and fludrocortisone replacement. Short synacthen tests 3 and 9 months later showed no recovery of adrenal function, although magnetic resonance imaging of the adrenal glands showed resolving adrenal haemorrhage. Adrenal insufficiency secondary to bilateral adrenal vein thrombosis and adrenal haemorrhage should be suspected in patients with VITT and treated promptly. Adrenal vein thrombosis can occur either as the initial presentation of VITT or days to weeks after the development of thrombosis in other sites. Further studies are required to provide insight on adrenal function recovery after VITT. Learning points: Adrenal insufficiency secondary to bilateral adrenal vein thrombosis and adrenal cortex haemorrhage should be suspected in patients with vaccine-induced thrombosis and thrombocytopenia (VITT) and treated promptly. Adrenal vein thrombosis can occur as the initial presentation of VITT or even days to weeks later after the development of thrombosis in other more classic sites (e.g. pulmonary or cerebral vasculature). Completion of vaccination schedule against SARS-CoV-2 post-VITT using an mRNA-based vaccine should be recommended to patients post-VITT as mRNA-based vaccines have not been associated with VITT but confer protection against SARS-CoV-2. There is paucity of data regarding the potential for recovery of adrenal function after bilateral adrenal haemorrhage in the context of VITT, and thus, more studies are needed to inform clinical practice. The need for disease registries for rare conditions, such as VITT, is crucial as direct cooperation and sharing of information by clinicians might enable quicker identification of disease patterns than would have been possible via established reporting tools of adverse events.
ABSTRACT
Background: Several studies have found increased risks of thrombosis with thrombocytopenia syndrome (TTS) following the ChAdOx1 vaccination. However, case ascertainment is often incomplete in large electronic health record (EHR)-based studies. Objectives: To assess for an association between clinically validated TTS and COVID-19 vaccination. Methods: We used the self-controlled case series method to assess the risks of clinically validated acute TTS after a first COVID-19 vaccine dose (BNT162b2 or ChAdOx1) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Case ascertainment was performed uninformed of vaccination status via a retrospective clinical review of hospital EHR systems, including active ascertainment of thrombocytopenia. Results: One hundred seventy individuals were admitted to the hospital for a TTS event at the study sites between January 1 and March 31, 2021. A significant increased risk (relative incidence [RI], 5.67; 95% confidence interval [CI], 1.02-31.38) of TTS 4 to 27 days after ChAdOx1 was observed in the youngest age group (18- to 39-year-olds). No other period had a significant increase, although for ChAdOx1 for all ages combined the RI was >1 in the 4- to 27- and 28- to 41-day periods (RI, 1.52; 95% CI, 0.88-2.63; and (RI, 1.70; 95% CI, 0.73-3.8, respectively). There was no significant increased risk of TTS after BNT162b2 in any period. Increased risks of TTS following a positive SARS-CoV-2 test occurred across all age groups and exposure periods. Conclusions: We demonstrate an increased risk of TTS in the 4 to 27 days following COVID-19 vaccination, particularly for ChAdOx1. These risks were lower than following SARS-CoV-2 infection. An alternative vaccine may be preferable in younger age groups in whom the risk of postvaccine TTS is greatest.
ABSTRACT
OBJECTIVES: We sought to characterise the outcomes of patients with haematological malignancy and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in hospital in our regional network of 7 hospitals. METHODS: Consecutive hospitalised patients with haematological malignancy and SARS-CoV-2 infection were identified from 01/03/2020 to 06/05/2020. Outcomes were categorised as death, resolved or ongoing. The primary outcome was preliminary case fatality rate (pCFR), defined as the number of cases resulting in death as a proportion of all diagnosed cases. Analysis was primarily descriptive. RESULTS: 66 Patients were included, overall pCFR was 51.5%. Patients ≥ 70 years accounted for the majority of hospitalised cases (42, 63%) and fatalities (25, 74%). Mortality was similar between females (52%) and males (51%). Immunosuppressive or cytotoxic treatment within 3 months of the diagnosis of SARS-CoV-2 infection was associated with a significantly higher pCFR of 70%, compared with 28% in those not on active treatment (P = .0013, 2 proportions z test). CONCLUSIONS: Mortality rates in patients with haematological malignancy and SARS-CoV-2 infection in hospital are high supporting measures to minimise the risk of infection in this population.