Episode 9 - COVID-19 Series: Part 2 - Vaccine-Induced Thrombotic Thrombocytopenia

COVID-19 series: In this segment, we discuss vaccine-induced thrombotic thrombocytopenia. The interlude segment will be presented by Prof. Sanjay Swaminathan (immunologist).

Theme
COVID-19. 

Participants
Dr Nicole Gilroy (infectious diseases specialist), Prof. Sanjay Swaminathan (immunologist), Dr Caroline Bahn (infectious diseases advanced trainee), Dr James Tadros (ED consultant), Dr Pramod Chandru (ED consultant), Harry Hong, Samoda Wilegoda Mudalige, Shreyas Iyer, Kit Rowe, and Caroline Tyers.

Discussion 2:
Sharifian-Dorche, M., Bahmanyar, M., Sharifian-Dorche, A., Mohammadi, P., Nomovi, M., & Mowla, A. (2021). Vaccine-induced immune thrombotic thrombocytopenia and cerebral venous sinus thrombosis post COVID-19 vaccination; a systematic review. Journal Of The Neurological Sciences, 428, 117607. https://doi.org/10.1016/j.jns.2021.117607.

Presenter - Vincent Tsui, ED Trainee at Westmead Hospital.

Summary:
  • According to the European Medicine Agency's Pharmacovigilance Risk Assessment Committee, 169 cases of central venous sinus thrombosis and 53 cases of splanchnic vein thrombosis were reported from 34 million people who had received the AstraZeneca COVID-19 vaccine. 
  • This systematic review examines published cases of vaccine-induced thrombotic thrombocytopaenia and central venous sinus thrombosis following the Astra Zeneca, Johnson & Johnson, and Janssen COVID-19 vaccines, to comment on the incidence, symptoms, investigations, treatment, and complications. 
  • Only English papers were included in their review. 
  • 12 papers on Astra Zeneca vaccination and 2 papers on the Johnson and Johnson vaccine were included, out of the 877 articles identified in their search.  
  • The most common symptom of CVST was headache (and there was no characteristic development or distribution of the headache). 
  • In their case series, there were 54 cases of CVST, with 36 of these being women.  
  • Most patients had their symptom onset within one week following the first vaccination (with a range from 4-19 days following vaccination).
  • Most patients with CVST had a platelet abnormality, with all patients having a positive D-dimer and platelet factor IV immunoglobulin.  
  • The recommended treatment for these patients is anticoagulation, and avoidance of administration platelets (in addition to IVIG and/or plasmapheresis).  
 Take-Home Points:
  • This is a very rare disease even in presence of COVID-19 vaccines. 
  • It is also a very difficult disease to diagnose, although early recognition is critical with regard to morbidity and mortality.  
  • The ACEM guide and local health district pathways for diagnosing VITT reflect the findings of this systematic review.  
  • The public response to the information surrounding VITT and the resultant vaccine hesitancy reflects the changing nature of health information and consent in modern medicine. 

References:
Burnet.edu.au. 2021. Initial modelling projections for second epidemic wave in Sydney, NSW | Burnet Institute. [online] Available at: https://www.burnet.edu.au/news/1506_initial_modelling_projections_for_second_epidemic_wave_in_sydney_nsw.

Interlude Segment:
Presenter - Prof. Sanjay Swaminathan.


Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 


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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

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