Case2. Vaccine induced thrombotic thrombocytopenia (VITT)
A 70-year-old female with a past medical history of diabetes mellitus
type 2, hypertension, and coronary artery disease (had undergone
percutaneous coronary intervention 10 years ago) received her first shot
of COVID19 AstraZeneca vaccine in late May 2021(day 0). The following
day she developed a generalized persistent headache that, despite
consumption of acetaminophen, didn’t improve. The next day she
experienced a single episode of generalized tonic-clonic seizure that
led to refer to the local hospital. During the hospital stay, laboratory
findings revealed a mild leukocytosis (WBC: 12000/μL), mildly elevated
Aspartate aminotransferase test (AST: 60U/L), an increased Lactic Acid
Dehydrogenase (LDH: 630U/L) and a high creatine phosphokinase level
(CPK: 450mcg/L) however the rest (BUN, Creatinine, ESR, CRP and urine
analysis) were normal. The neuroimaging findings including brain
computed tomography (CT), magnetic resonance imaging (MRI) imaging, and
magnetic resonance venography (MRV), were unremarkable. The patient was
discharged five days later due to normal workups, no new seizure and
amelioration of her headache.
After a few days, headache and convulsions commenced again, and their
severity and frequency worsened gradually that finally led to
hospitalization at our center after approximately two weeks (day 21). At
the admission, the patient was lethargic and was experiencing seizure
episodes 2-3 times per day, each one lasting 2-3 minutes. Clinical and
neurologic examinations showed no remarkable findings, and all her vital
signs were within a normal range (BP: 120/80, T: 36.8°C, HR: 75, RR: 14,
O2sat:96%). The primary ECG showed no pathologic findings. At this
time, moderate thrombocytopenia [78× 103 /ml; normal reference range
(NRR) 150–450 × 103 /ml] with normal peripheral blood smear
morphology, markedly elevated D-dimer (11 µg/ml (<0.5)), a
fibrinogen level at the lower limit of the normal range, anemia (Hgb:
9.4g/dl) and elevated inflammatory markers (ESR: 45 mm/1hr, CRP: 25
mg/L) were detected. Other blood tests were normal. Thus,
vaccine-induced thrombotic thrombocytopenia (VITT) was suggested(9) and,
further investigations were requested.
The anti-PF4 IgG antibody ELISA tests was positive (380 ng/ml
(42.1-313.40)). Brain CT venography findings were in favor of cerebral
venous sinus (sagittal sinus) thrombosis (CVST), so the patient
underwent brain MRI. In brain MRI, periventricular abnormal signals
without diffusion restriction were seen in favor of small vessel,
ischemic changes (FAZEKAS III) and T2 and diffusion-weighted signal
changes representative of acute infarction was also visible in left
occipital lobe. In brain MRV filling defect in favor of left transverse
sinus thrombosis was seen (figure2). Finally, brain and cervical MRA
were also unremarkable and no pathologic finding was observed.
During hospital stay, Intravenous immunoglobulin (IVIG) (1gr/kg/day for
2 days), corticosteroids (0.5 mg/kg prednisolone), rivaroxaban (15
mg/BID), sodium valproate and levetiracetam were started. Convulsions
ceased within two days, and platelet began going up on the 3rd day. The
patient’s general condition gradually improved, seizures were
controlled, the patient’s D-dimer decreased, and platelets and
hemoglobin returned to normal and after 10 days, the patient was
discharged from the hospital with continued anticoagulants and
anticonvulsants drugs.