Refractory vaccine‐induced immune thrombotic thrombocytopenia (<scp>VITT</scp>) managed with delayed therapeutic plasma exchange (<scp>TPE</scp>)
Ajay Major, Timothy Carll, Clarence W. Chan, Chancey Christenson, Fatima Aldarweesh, Geoffrey D. Wool, Kenneth S. Cohen
Abstract
Abstract Vaccine‐induced immune thrombotic thrombocytopenia (VITT) is a newly described hematologic disorder, which presents as acute thrombocytopenia and thrombosis after administration of the ChAdOx1 nCov‐19 (AstraZeneca) and Ad26.COV2.S (Johnson & Johnson) adenovirus‐based vaccines against COVID‐19. Due to positive assays for antibodies against platelet factor 4 (PF4), VITT is managed similarly to autoimmune heparin‐induced thrombocytopenia (HIT) with intravenous immunoglobulin (IVIG) and non‐heparin anticoagulation. We describe a case of VITT in a 50‐year‐old man with antecedent alcoholic cirrhosis who presented with platelets of 7 × 10 3 /μL and portal vein thrombosis 21 days following administration of the Ad26.COV2.S COVID‐19 vaccine. The patient developed progressive thrombosis and persistent severe thrombocytopenia despite IVIG, rituximab and high‐dose steroids and had persistent anti‐PF4 antibodies over 30 days after his initial presentation. As such, delayed therapeutic plasma exchange (TPE) was pursued on day 32 of admission as salvage therapy, with a sustained improvement in his platelet count. Our case serves as proof‐of‐concept of the efficacy of TPE in VITT.