Portal Vein Thrombosis due to Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT) after Covid Vaccination with ChAdOx1 nCoV-19

A 29-year-old male graduate student was vaccinated with the recombinant adenoviral vector encoding the spike protein antigen of SARS-CoV-2 (Astra-Zeneca Vaxzevria). He developed upper abdominal pain without nausea or vomiting 14 days after vaccination. The abdominal symptoms were followed by headache two days later. He interpreted his symptoms as stress related to the finalization of his master’s degree thesis. Two days later he noticed skin petechia and went to the emergency medical service. The clinical presentation with headache and a high D-dimer concentration prompted his referral to the university hospital. At admission, the patient was afebrile and had no signs of infection and no neurologic deficits. Laboratory results were significant for severe thrombocytopenia (21 000/ml). Magnetic resonance imaging (MRI) of his head showed thrombosis of the transversus/sigmoideus transition extending towards the left vena jugularis interna. Abdominal ultrasound revealed thrombosis of the portal vein including the intrahepatic branches and extending to the confluence of the splenic vein and superior mesenteric vein ([Fig. 1]). No free fluid and no bowel wall thickening were seen. Spleen size was normal. Vaccine-induced immune thrombotic thrombocytopenia (VITT) was suspected in this otherwise healthy young man, who had not been exposed to heparin before. Argatroban was administered at a dose of 2 micrograms/kg/min as an intravenous infusion. The patient was treated with intravenous immunoglobulin (1 g per kilogram per day for two days) and prednisolone (100 mg per day for three days). Platelet counts normalized within three days. Oral anticoagulation with apixaban was started when the platelet count was > 100 000/ml. The patientʼs symptoms resolved within 72 hours, follow-up abdominal ultrasound four days after admission showed subtotal resolution of thrombosis indicating a favorable outcome ([Fig. 2]). The patient was discharged from hospital six days after admission. Antibody-mediated PF4-dependent platelet activation was later confirmed in a blood sample taken before intravenous immunoglobulin treatment.

Publication History

Article published online:
01 October 2021

• References

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