Thrombosis with Thrombocytopenia Syndrome (TTS) After ChAdOx1 nCoV-19 Immunization: An Investigative Case Report.

e-ISSN 1941-5923 © Am J Case Rep, 2023; 24: e938878 DOI: 10.12659/AJCR.938878 Received: Accepted: Available online: Published: Thrombosis with Thrombocytopenia Syndrome (TTS) After ChAdOx1 nCoV-19 Immunization: An Investigative Case Report 2022.11.06 2023.01.25 2023.02.13 2023.03.18 Authors’ Contribution: Study Design A Data Collection B Statistical Analysis C Data Interpretation D Manuscript Preparation E Literature Search F Funds Collection G ACDEFG 1,2 BDE 3 BDE 3 BDE 3 BDE 3 BCE 3 ABCDEFG 3 Corresponding Authors: Financial support: Conflict of interest: Patient: Final Diagnosis: Symptoms: Clinical Procedure: Specialty: Objective: Background: Case Report: Conclusions: Keywords: Full-text PDF: Nityanand Jain Piyush Chaudhary Amit Shrivastava Taranvir Kaur Shabjot Kaur Harmandeep Singh Brar Ravul Jindal 1 Faculty of Medicine, Riga Stradinš University, Riga, Latvia 2 Statistics Unit, Riga Stradinš University, Riga, Latvia 3 Department of Vascular Surgery, Fortis Hospital Mohali, Sahibzada Ajit Singh Nagar (Mohali), Punjab, India Nityanand Jain, e-mail: , Ravul Jindal, e-mail: None declared None declared Male, 18-year-old Thrombosis with thrombocytopenia syndrome • probable vaccine-induced immune thrombotic thrombocytopenia Headache • hemiparesis • intracranial hemorrhage • thrombocytopenia • vomiting Decompressive craniotomy • exploratory laparotomy • small bowel anastomosis • IVIG administration Surgery Unusual clinical course Thrombosis with thrombocytopenia syndrome (TTS), including vaccine-induced immune thrombotic thrombocytopenia (VITT), is an extremely rare adverse effect, mostly seen after initial vaccination with the viral vectorbased AstraZeneca-Oxford COVID-19 vaccine. It is characterized by mild to severe thrombocytopenia and venous or arterial thrombosis. Herein, we present a case of an 18-year-old male patient who developed Level 1 TTS (probable VITT) eight days after immunization with the ChADOx1 nCOV-19 vaccine (Covishield; AZ-Oxford). Initial investigations revealed severe thrombocytopenia, hemiparesis, and intracranial hemorrhage, after which the patient was treated conservatively. However, a decompressive craniotomy was performed later due to patient deterioration. One week after surgery, the patient developed bilious vomiting, lower-gastrointestinal bleeding, and abdominal distension. An abdominal CT scan was performed that showed thrombosis of the portal vein with occlusion of the left iliac vein. The patient underwent an exploratory laparotomy followed by resection and anastomosis of the small bowel due to massive gut gangrene. Due to persistent thrombocytopenia after surgery, intravenous immune globulin (IVIG) was administered. The platelet count increased thereafter, and the patient stabilized. He was discharged on the 33rd day after admission and was followed up for a year. No post-hospitalization complications were observed in the follow-up period. Although vaccines have been proven to be highly safe and effective to end the Coronavirus Disease 2019 (COVID-19) caused pandemic, there is still a small risk of developing rare complications, including TTS and VITT. Early diagnosis and prompt intervention are key for patient management. ChAdOx1 nCoV-19 • COVID-19 Vaccines • Headache • Immunoglobulins • Thrombocytopenia • Venous Thrombosis https://www.amjcaserep.com/abstract/index/idArt/938878 2391   2   6   27 Publisher’s note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) e938878-1 Indexed in: [PMC] [PubMed] [Emerging Sources Citation Index (ESCI)] [Web of Science by Clarivate] Jain N. et al: TTS after COVID-19 immunization © Am J Case Rep, 2023; 24: e938878 Background COVID-19 is a SARS-COV-2 (severe acute respiratory syndrome coronavirus-2)-mediated viral infection presenting with varying degrees of clinical severity and symptomology [1]. Since the first documented case of COVID-19 in China in 2019, more than 84 million cases and 1.8 million deaths have been reported globally (as of 1st November 2022). Given its high transmission rate, voluntary mass vaccination plays a crucial role in stemming the transmission of the virus. Additionally, vaccination spikes the immune system, thereby reducing the severity of the disease in infected individuals. Among the various available COVID-19 vaccines, the recombinant chimpanzee Ad25 vector-based AstraZeneca-Oxford (AZ-Oxford) vaccine is one of the most used vaccines globally, available for use in 182 countries [2]. The AZ-Oxford vaccine manufactured in India is branded as Covishield and was found to be identical in composition and immunogenicity to the parent vaccine [3]. Such vector-based vaccines can induce CD4+ T cell-mediated Th1 immune responses, thereby conferring the recipient stronger immune protection [4]. Malaise, fatigue, headache, myalgia, injection site pain/tenderness are the most reported adverse events following immunization with the AZ-Oxford vaccine [5], most of which can be resolved by taking over-the-counter pain medications like paracetamol and NSAIDs (eg, ibuprofen). However, in some patients, rather rare but life-threatening adverse effects presenting as thrombocytopenia and thrombosis at unusual localizations have been reported. The condition has been termed vaccine-induced immune thrombotic thrombocytopenia (VITT). Although the exact pathogenetic mechanism and the incidence of the condition are unknown, VITT has been estimated to have a case fatality rate of 23-40% [6]. Since the risk of VITT development following COVID-19 vaccination is relatively small (1 case per 26 500 to 127 300 population), the FDA (Food and Drug Administration, USA) has recommended that vector-based vaccines be given only to individuals older than 18 years of age who are otherwise ineligible to receive any other vaccines [6,7]. Clinically, the American Society of Hematology defines VITT as a clinical syndrome presenting 4-42 days after immunization with vector-based vaccines and characterized by the presence of all of the following changes in laboratory and radiological examinations: a) thrombosis at uncommon localizations including cerebral venous sinus thrombosis/splanchnic venous thrombosis; b) mild to severe thrombocytopenia; c) positive antibodies against platelet factor-4 (PF-4) identified by quantitative ELISA (enzyme-linked immunosorbent assay) and d) significantly elevated D-dimer (>4 times upper normal limits) [7]. Thrombosis with thrombocytopenia syndrome (TTS), This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 Internationa (...truncated)