Thromboembolism after Astra Zeneca COVID-19 vaccine: Not always PF4- antibody mediated

Figures & data

Figure 1. Our decisional matrix for the diagnosis/suspicion of VIPIT, clinical data, i.e. suspicion of thrombosis after AZD 1222 vaccination was the main cause for undergoing this matrix.

Table 1. Overview over important lab values of the five patients, based on IgG alone (7), measured values based on IgG and IgM.¹².

Patient	1	2	3	4	5
Age	60	50	33	30	40
Sex	Male	Male	Male	Male	Male
Days since vaccination	7	15	13	14	7
Max hsTNT [ng/L; normal < 14]	6	5	520	15	216
d-dimer value [mg/FEU normal < 0.5]	1,8	1,86	63	8,94	130
Thrombocyte count [G/L, normal < 150]	208	157	60	31	7
Levels of S-Protein (IgG + IgM) [U/mL, Expected IgG IQR*]	Not measured	7.82 (43.7–186) low	31.8 (43.7–186), low	Not measured	0.72 (1–1.8), low
PF4- antibody HIT test	Not detectable	Not detectable	Not detectable	Not measured	Detectable
Hospitalization days	4	0	6	33	54
HIT II Test	Negative	Negative	Negative	Negative	Negative
Pulmonary embolism in CT scan	Yes	Yes	Yes	No	Yes
Portal vein thrombosis	No	No	No	Yes	Yes
COVID −19 PCR	Negative	Negative	Negative	Negative	Negative
Localization of the thrombosis	PE and DVT	PE	PE and DVT	MVT and PVT	PE, MVT and PVT
Reach of the thrombosis	Diffuse	Localized (outpatient scan)	Diffuse	Diffuse	diffuse

*IQR = interquartile range, mg = milligram, hsTNT = high sensitive Troponin T, IgG = immunoglobulin G, IgM = immunoglobulin M, U = units, PF4 platelet factor 4, HIT = Heparin induced thrombocytopenia, PCR = polymerase chain reaction PE = pulmonary embolism, DVT = deep vein thrombosis, MVT = mesenteric vein thrombosis, PVT = portal vein thrombosis: The severity of the disease correlates with high hsTNT, d-dimer values and anti PF4-antibodies, low anti-spike-protein-antibody levels, and extensive and diffuse thrombus burden.

Figure 2. FCT scans of patients with suspected or confirmed VIPIT: The first scan (a) shows the pulmonary embolism in patient 1, the next two scans (b) shows the pulmonary embolism inpatient 3 and its diffuse pattern. The third scan series (c) show the mesenterial thrombosis in patient 4, and the last four scans (d) shows the mesenterial thrombosis and its extent in patient 5, with a positive anti PF4-test. They both show an extensive portal vein thrombosis (red arrow), best seen in (c) when comparing jugular and mesenterial vein contrast and best seen in d, in the sagittal view, when comparing arterial and venous phase. Both patients (c and d) show a extensive diffuse mesenteric thrombosis originating from the complete thrombosis of the splenic vein, indicating a possible immunologic origin with potential thrombotic chain reaction.

Beavis KG, Matushek S, Abeleda PF, Bethel C, Hunt C, Gillen S, Moran A, Tesic V. Evaluation of the EUROIMMUN anti-SARS-COV-2 ELISA Assay for detection of IgA and IgG antibodies. J Clin Virol. 2020;129:104468. Published online 2020 May 23. doi:10.1016/j.jcv.2020.104468.

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