Adjunct Immune Globulin for Vaccine-Induced Immune Thrombotic Thrombocytopenia

• Published in: The New England journal of medicine Vol. 385; no. 8; pp. 720 - 728
• Main Authors: Bourguignon, Alex, Arnold, Donald M, Warkentin, Theodore E, Smith, James W, Pannu, Tania, Shrum, Jeffrey M, Al Maqrashi, Zainab A.A, Shroff, Anjali, Lessard, Marie-Claude, Blais, Normand, Kelton, John G, Nazy, Ishac
• Format: Journal Article
• Language: English
• Published: United States Massachusetts Medical Society 19.08.2021
• Series: Brief Report
• Subjects: Aged; Antibodies; Anticoagulants; Anticoagulation; Blood platelets; Cardiology; ChAdOx1 nCoV-19; Coagulation; Coronavirus; Coronaviruses; COVID-19; COVID-19 vaccines; COVID-19 Vaccines - adverse effects; Critical Care; Female; Fibrin Fibrinogen Degradation Products - analysis; Fibrinogen - analysis; Globulins; Hematology; Heparin; Heparin - pharmacology; Hospitals; Humans; Immunoglobulins; Immunoglobulins, Intravenous; Infectious Disease; Intravenous administration; Laboratories; Male; Middle Aged; Neurology; Neurosurgery; Oncology; Original; Patients; Platelet Count; Platelet factor 4; Platelet Factor 4 - pharmacology; Platelets; Pulmonary; Pulmonary embolisms; Serotonin; Serotonin - blood; Stroke; Thrombocytopenia; Thrombocytopenia - blood; Thrombocytopenia - etiology; Thrombocytopenia - therapy; Thromboembolism; Thrombosis; Thrombosis - etiology; Thrombosis - immunology; Thrombosis - therapy; Vaccines; Veins & arteries
• ISSN: 0028-4793; 1533-4406
• DOI: 10.1056/NEJMoa2107051

The use of high-dose intravenous immune globulin (IVIG) plus anticoagulation is recommended for the treatment of vaccine-induced immune thrombotic thrombocytopenia (VITT), a rare side effect of adenoviral vector vaccines against coronavirus disease 2019 (Covid-19). We describe the response to IVIG therapy in three of the first patients in whom VITT was identified in Canada after the receipt of the ChAdOx1 nCoV-19 vaccine. The patients were between the ages of 63 and 72 years; one was female. At the time of this report, Canada had restricted the use of the ChAdOx1 nCoV-19 vaccine to persons who were 55 years of age or older on the basis of reports that VITT had occurred primarily in younger persons. Two of the patients in our study presented with limb-artery thrombosis; the third had cerebral venous and arterial thrombosis. Variable patterns of serum-induced platelet activation were observed in response to heparin and platelet factor 4 (PF4), indicating the heterogeneity of the manifestations of VITT in serum. After the initiation of IVIG, reduced antibody-induced platelet activation in serum was seen in all three patients. (Funded by the Canadian Institutes of Health Research.) A rare side effect of ChAdOx1 nCoV-19 vaccination against Covid-19 — venous or arterial thrombosis, which has been termed vaccine-induced immune thrombotic thrombocytopenia — has been reported in recent months. In this Brief Report, investigators describe the use of intravenous immune globulin in the treatment of three such vaccine recipients in Canada.