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2.
J Stroke Cerebrovasc Dis ; 30(11): 106072, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1377775

ABSTRACT

Recently cases of vaccine-induced immune thrombotic thrombocytopenia (VITT) and thrombosis following the adenoviral vector vaccine against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were reported. A mechanism similar to heparin-induced thrombocytopenia was proposed with antibodies to platelet factor 4 (PF4). Vaccine related arterial thrombosis in the brain is rare but life-threatening and optimal treatment is not established. We report clinical, laboratory, imaging findings and treatment in a 51-year-old female presenting with acute left middle cerebral artery (MCA) occlusion 7 days after the first dose of ChAdOx1 nCoV-19 vaccine. Due to low platelet count and suspicion of VITT she was not eligible for intravenous thrombolysis (IVT) and proceeded to mechanical thrombectomy (MER) with successful recanalization four hours after onset of symptoms. Treatment with intravenous immunoglobulin (IVIG) and heparin pentasaccharide fondaparinux was initiated. Presence of anti-PF4 antibodies was confirmed. The patient improved clinically with normalization of platelet count. Clinicians should be alert of VITT in patients with acute ischemic stroke after ChAdOx1 nCov-19 vaccination and low platelet counts. MER showed to be feasible and effective. We propose considering MER in patients with VITT and large vessel occlusion despite thrombocytopenia. High-dose IVIG should be started immediately. Alternative anticoagulation to heparin should be started 24 hours after stroke onset unless significant hemorrhagic transformation occurred. Platelet transfusion is contraindicated and should be considered only in severe hemorrhagic complications. Restenosis or reocclusion of the revascularized artery is possible due to the hypercoagulable state in VITT and angiographic surveillance after the procedure is reasonable.


Subject(s)
COVID-19 Vaccines/adverse effects , COVID-19/prevention & control , Infarction, Middle Cerebral Artery/chemically induced , Ischemic Stroke/chemically induced , Purpura, Thrombocytopenic, Idiopathic/chemically induced , Anticoagulants/therapeutic use , COVID-19/immunology , COVID-19/virology , Female , Humans , Immunoglobulins, Intravenous/therapeutic use , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/immunology , Infarction, Middle Cerebral Artery/therapy , Ischemic Stroke/diagnostic imaging , Ischemic Stroke/immunology , Ischemic Stroke/therapy , Middle Aged , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombocytopenic, Idiopathic/immunology , Purpura, Thrombocytopenic, Idiopathic/therapy , Thrombectomy , Treatment Outcome
4.
N Engl J Med ; 385(18): 1680-1689, 2021 10 28.
Article in English | MEDLINE | ID: covidwho-1352005

ABSTRACT

BACKGROUND: Vaccine-induced immune thrombocytopenia and thrombosis (VITT) is a new syndrome associated with the ChAdOx1 nCoV-19 adenoviral vector vaccine against severe acute respiratory syndrome coronavirus 2. Data are lacking on the clinical features of and the prognostic criteria for this disorder. METHODS: We conducted a prospective cohort study involving patients with suspected VITT who presented to hospitals in the United Kingdom between March 22 and June 6, 2021. Data were collected with the use of an anonymized electronic form, and cases were identified as definite or probable VITT according to prespecified criteria. Baseline characteristics and clinicopathological features of the patients, risk factors, treatment, and markers of poor prognosis were determined. RESULTS: Among 294 patients who were evaluated, we identified 170 definite and 50 probable cases of VITT. All the patients had received the first dose of ChAdOx1 nCoV-19 vaccine and presented 5 to 48 days (median, 14) after vaccination. The age range was 18 to 79 years (median, 48), with no sex preponderance and no identifiable medical risk factors. Overall mortality was 22%. The odds of death increased by a factor of 2.7 (95% confidence interval [CI], 1.4 to 5.2) among patients with cerebral venous sinus thrombosis, by a factor of 1.7 (95% CI, 1.3 to 2.3) for every 50% decrease in the baseline platelet count, by a factor of 1.2 (95% CI, 1.0 to 1.3) for every increase of 10,000 fibrinogen-equivalent units in the baseline d-dimer level, and by a factor of 1.7 (95% CI, 1.1 to 2.5) for every 50% decrease in the baseline fibrinogen level. Multivariate analysis identified the baseline platelet count and the presence of intracranial hemorrhage as being independently associated with death; the observed mortality was 73% among patients with platelet counts below 30,000 per cubic millimeter and intracranial hemorrhage. CONCLUSIONS: The high mortality associated with VITT was highest among patients with a low platelet count and intracranial hemorrhage. Treatment remains uncertain, but identification of prognostic markers may help guide effective management. (Funded by the Oxford University Hospitals NHS Foundation Trust.).


Subject(s)
COVID-19 Vaccines/adverse effects , Purpura, Thrombocytopenic, Idiopathic/etiology , Thrombosis/etiology , Adolescent , Adult , Aged , Anticoagulants , Autoantibodies/blood , COVID-19/prevention & control , Female , Humans , Immunoglobulins, Intravenous/therapeutic use , Intracranial Hemorrhages/etiology , Intracranial Hemorrhages/mortality , Male , Middle Aged , Multivariate Analysis , Platelet Count , Platelet Factor 4/immunology , Prospective Studies , Purpura, Thrombocytopenic, Idiopathic/mortality , Purpura, Thrombocytopenic, Idiopathic/therapy , Risk Factors , Thrombosis/drug therapy , Thrombosis/mortality , United Kingdom/epidemiology , Young Adult
5.
Blood ; 138(4): 293-298, 2021 07 29.
Article in English | MEDLINE | ID: covidwho-1331924

ABSTRACT

The development of vaccines to fight COVID-19 has been a remarkable medical achievement. However, this global immunization effort has been complicated by a rare vaccine-related outcome characterized by thrombocytopenia and thrombosis in association with platelet-activating anti-platelet factor 4 antibodies. In this Spotlight, we will discuss the recently described complication of vaccine-induced immune thrombotic thrombocytopenia (VITT) occurring in response to certain COVID-19 vaccines. Although information about this clinical condition is rapidly evolving, we will summarize our current understanding of VITT.


Subject(s)
COVID-19 Vaccines/adverse effects , COVID-19/prevention & control , Purpura, Thrombocytopenic, Idiopathic/etiology , Anticoagulants/adverse effects , Anticoagulants/immunology , COVID-19/immunology , COVID-19 Vaccines/immunology , COVID-19 Vaccines/therapeutic use , Disease Management , Heparin/adverse effects , Heparin/immunology , Humans , Purpura, Thrombocytopenic, Idiopathic/immunology , Purpura, Thrombocytopenic, Idiopathic/therapy , SARS-CoV-2/immunology
7.
Br J Haematol ; 195(3): 365-370, 2021 11.
Article in English | MEDLINE | ID: covidwho-1255364

ABSTRACT

There is concern that COVID-19 vaccination may adversely affect immune thrombocytopenia (ITP) patients. Fifty-two consecutive chronic ITP patients were prospectively followed after COVID-19 vaccination. Fifteen percent had no worsening of clinical symptoms but no post-vaccination platelet count; 73% had no new symptoms and no significant platelet count decline. However, 12% had a median platelet count drop of 96% within 2-5 days post vaccination with new bleeding symptoms; after rescue therapy with corticosteroids +/- intravenous immunoglobulin (IVIG), platelets recovered to >30 × 109 /l a median three days later. ITP exacerbation occurred independently of remission status, concurrent ITP treatment, or vaccine type. Safety of a second vaccine dose needs careful assessment.


Subject(s)
COVID-19 Vaccines/adverse effects , COVID-19/prevention & control , Hemorrhage/etiology , Purpura, Thrombocytopenic, Idiopathic/complications , Adrenal Cortex Hormones/therapeutic use , Adult , Aged , COVID-19/complications , COVID-19/pathology , Female , Follow-Up Studies , Hemorrhage/pathology , Hemorrhage/therapy , Humans , Immunoglobulins, Intravenous/therapeutic use , Male , Middle Aged , Platelet Count , Prospective Studies , Purpura, Thrombocytopenic, Idiopathic/pathology , Purpura, Thrombocytopenic, Idiopathic/therapy , Severity of Illness Index , Young Adult
8.
Blood ; 138(4): 293-298, 2021 07 29.
Article in English | MEDLINE | ID: covidwho-1249542

ABSTRACT

The development of vaccines to fight COVID-19 has been a remarkable medical achievement. However, this global immunization effort has been complicated by a rare vaccine-related outcome characterized by thrombocytopenia and thrombosis in association with platelet-activating anti-platelet factor 4 antibodies. In this Spotlight, we will discuss the recently described complication of vaccine-induced immune thrombotic thrombocytopenia (VITT) occurring in response to certain COVID-19 vaccines. Although information about this clinical condition is rapidly evolving, we will summarize our current understanding of VITT.


Subject(s)
COVID-19 Vaccines/adverse effects , COVID-19/prevention & control , Purpura, Thrombocytopenic, Idiopathic/etiology , Anticoagulants/adverse effects , Anticoagulants/immunology , COVID-19/immunology , COVID-19 Vaccines/immunology , COVID-19 Vaccines/therapeutic use , Disease Management , Heparin/adverse effects , Heparin/immunology , Humans , Purpura, Thrombocytopenic, Idiopathic/immunology , Purpura, Thrombocytopenic, Idiopathic/therapy , SARS-CoV-2/immunology
9.
Pediatr Hematol Oncol ; 38(7): 663-668, 2021 Oct.
Article in English | MEDLINE | ID: covidwho-1216504

ABSTRACT

Patients with coronavirus disease 2019 (COVID-19) from novel coronavirus (SARS-CoV-2) infection may present with immune thrombocytopenia (ITP). Multisystem inflammatory syndrome in children (MIS-C) is a serious complication of SARS-CoV-2 causing systemic organ dysfunction. This case series presents the first reported cases of patients who developed ITP following MIS-C, while completing corticosteroid tapers. These patients responded to standard of care therapies for ITP and had appropriate platelet count recovery. We emphasize the importance of careful monitoring of those recovering from COVID-19 or MIS-C, to proactively identify clinical and laboratory abnormalities, in addition to long-term cardiovascular sequelae.


Subject(s)
COVID-19/complications , Purpura, Thrombocytopenic, Idiopathic/etiology , Systemic Inflammatory Response Syndrome/complications , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Aspirin/therapeutic use , COVID-19/blood , COVID-19/therapy , Child , Disease Management , Glucocorticoids/therapeutic use , Humans , Infant , Male , Methylprednisolone/therapeutic use , Platelet Count , Prednisolone/therapeutic use , Purpura, Thrombocytopenic, Idiopathic/blood , Purpura, Thrombocytopenic, Idiopathic/therapy , Systemic Inflammatory Response Syndrome/blood , Systemic Inflammatory Response Syndrome/therapy
10.
Transfusion ; 61(7): 2014-2018, 2021 07.
Article in English | MEDLINE | ID: covidwho-1136057

ABSTRACT

BACKGROUND: Immune thrombocytopenia (ITP) is an acquired disease characterized by thrombocytopenia secondary to autoantibodies against platelets. Here, we report the clinical characteristics of coronavirus disease 2019 (COVID-19)-induced ITP cases. STUDY DESIGN AND METHODS: We retrospectively reviewed 3255 COVID-19 patients. COVID-19-induced ITP was diagnosed after excluding possible common causes. Bleeding severity was assessed based on the modified World Health Organization (WHO) bleeding severity score. RESULTS: We identified 11 (0.34%) patients with COVID-19-induced ITP. Of all patients, 63.6% were males and the median age was 63 years. The median time from COVID-19 diagnosis to the onset of ITP was 10 days. Bleeding observed in 63.6% of the patients. Clinically significant bleeding (WHO Grade 3) occurred in single patient who required blood transfusion. Standard treatment with glucocorticoids and intravenous immunoglobulin (IVIG) was effective in achieving excellent response in most cases. Of all patients, complete response and response to treatment were achieved in 45.5% and 27.3% patients, respectively. The median time to ITP recovery was 4 days. Eltrombopag was used in three patients who relapsed. Four patients required mechanical ventilation, and none of them survived secondary to hypoxic respiratory failure. CONCLUSION: ITP secondary to COVID-19 usually presents after the first week of symptoms beginning. Most of our patients had WHO Grade 1-2 bleeding scores. Standard treatment with glucocorticoids and IVIG is effective in achieving an excellent response. The safety of eltrombopag is not very well established in COVID-19 patients, and additional studies are needed for a better safety profile.


Subject(s)
COVID-19/complications , COVID-19/epidemiology , Purpura, Thrombocytopenic, Idiopathic/epidemiology , Purpura, Thrombocytopenic, Idiopathic/etiology , Adult , Aged , Aged, 80 and over , Biomarkers , COVID-19/diagnosis , COVID-19/virology , COVID-19 Testing , Disease Management , Disease Susceptibility , Female , Humans , Immunoglobulins, Intravenous/therapeutic use , Male , Middle Aged , Platelet Count , Purpura, Thrombocytopenic, Idiopathic/diagnosis , Purpura, Thrombocytopenic, Idiopathic/therapy , Retrospective Studies , SARS-CoV-2 , Treatment Outcome
16.
Int J Infect Dis ; 99: 269-271, 2020 Oct.
Article in English | MEDLINE | ID: covidwho-696202

ABSTRACT

The novel coronavirus SARS-CoV-2 can cause a severe and even fatal respiratory illness named COVID-19. Apart from respiratory failure, COVID-19 may be associated with various autoimmune complications. We present a case of a critically ill patient with COVID-19 who developed severe immune thrombocytopenia that was successfully treated with a concomitant use of corticosteroids and intravenous immunoglobulins.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Pneumonia, Viral/complications , Purpura, Thrombocytopenic, Idiopathic/etiology , COVID-19 , Critical Illness , Humans , Male , Middle Aged , Pandemics , Platelet Transfusion , Purpura, Thrombocytopenic, Idiopathic/therapy , SARS-CoV-2
17.
BMJ Case Rep ; 13(7)2020 Jul 07.
Article in English | MEDLINE | ID: covidwho-638342
20.
Int J Hematol ; 112(5): 746-750, 2020 Nov.
Article in English | MEDLINE | ID: covidwho-619933

ABSTRACT

COVID-19 is a new disease with many undescribed clinical manifestations. We report herein a case of severe immune thrombocytopenic purpura (ITP) in a critical COVID-19 patient. A patient presented a severe episode of immune thrombocytopenia (< 10 × 109/L) 20 days after admission for a critical COVID-19. This thrombocytopenia was associated with a life-threatening bleeding. Response to first-line therapies was delayed as it took up to 13 days after initiation of intravenous immunoglobulin and high-dose dexamethasone to observe an increase in platelet count. COVID-19 may be associated with late presenting severe ITP. Such ITP may also be relatively resistant to first-line agents. Hematological manifestations of COVID-19, such as the ones associated with life-threatening bleeding, must be recognized.


Subject(s)
Coronavirus Infections/complications , Pandemics , Pneumonia, Viral/complications , Purpura, Thrombocytopenic, Idiopathic/etiology , Betacoronavirus , COVID-19 , Combined Modality Therapy , Coronavirus Infections/drug therapy , Dexamethasone/therapeutic use , Hemorrhage/etiology , Humans , Immunoglobulins, Intravenous , Intracranial Hemorrhages/etiology , Male , Middle Aged , Pneumonia, Staphylococcal/etiology , Pneumonia, Ventilator-Associated/etiology , Pulmonary Atelectasis/etiology , Purpura, Thrombocytopenic, Idiopathic/drug therapy , Purpura, Thrombocytopenic, Idiopathic/therapy , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/therapy , SARS-CoV-2
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