Refractory vaccine-induced immune thrombotic thrombocytopenia (VITT) managed with delayed therapeutic plasma exchange (TPE)
Refractory vaccine-induced immune thrombotic thrombocytopenia (VITT) managed with delayed therapeutic plasma exchange (TPE)
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DOI：
10.1002/jca.21945
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发表时间：
2021-10-21
影响因子：
1.5
通讯作者：
Cohen, Kenneth S.
中科院分区：
文献类型：
--
作者：
Major, Ajay;Carll, Timothy;Cohen, Kenneth S.
疫苗诱导的免疫性血栓性血小板减少症（VITT）是一种新描述的血液学疾病，在接种ChAdOx 1 nCov-19（阿斯利康）和Ad26.COV2.S（约翰逊&约翰逊）基于腺病毒的COVID-19疫苗后表现为急性血小板减少症和血栓形成。由于血小板因子4（PF 4）抗体检测呈阳性，因此VITT的管理与静脉注射免疫球蛋白（IVIG）和非肝素抗凝治疗的自身免疫性肝素诱导的血小板减少症（HIT）相似。我们描述了一例50岁男性VITT病例，该男性患有酒精性肝硬化，在接种Ad26.COV2.S COVID-19疫苗后21天出现血小板7 x 10（3）/μ L和门静脉血栓形成。尽管使用了IVIG、利妥昔单抗和高剂量类固醇，患者仍发生了进行性血栓形成和持续性重度血小板减少症，并在首次就诊后30多天内出现持续性抗PF 4抗体。因此，在入院第32天进行延迟治疗性血浆置换（TPE）作为挽救治疗，血小板计数持续改善。我们的病例可作为TPE在VITT中有效性的概念验证。
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 x 10(3)/mu L 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.