Case Reports
Vol. 2 No. 2 (2023)
Long-term persistence of high anti-PF4 antibodies titer in a challenging case of AZD1222 vaccine-induced thrombotic thrombocytopenia
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Received: 19 March 2023
Accepted: 1 June 2023
Accepted: 1 June 2023
863
Views
263
Downloads
Authors
A syndrome occurring after adenoviral vector anti-SARS-CoV-2 vaccination, characterized by thrombocytopenia, venous thrombosis, and circulating anti-PF4 antibodies, known as vaccine-induced immune thrombotic thrombocytopenia (VITT), is well described. Data on the long-term course of this syndrome are lacking. Our aim is to report the clinical and laboratory features of a patient with VITT from diagnosis and during 21 months of follow-up. Cerebral venous thrombosis associated with elevated D-dimer, low fibrinogen, thrombocytopenia, and anti-PF4 antibodies positivity occurred in this patient after ChAdOx1 nCoV-19 vaccination. Cerebral thrombosis required a revascularization procedure and decompressive craniectomy. Upon dexamethasone and anticoagulant treatment initiation, the platelet count recovered. However, a persistently high anti-PF4 antibody titer, without thrombosis recurrence, was observed. Little is known about the long-term persistence of anti-PF4 antibodies, their clinical significance, and their possible role in guiding therapeutic decisions. In our patient, we decided to continue anticoagulant treatment beyond 21 months with parallel anti-PF4 antibody monitoring.
Downloads
Download data is not yet available.
Citations
Greinacher A, Thiele T, Warkentin TE, Weisser K, Kyrle PA, Eichinger S. Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination. N Engl J Med. 2021;384(22):2092-2101. DOI: https://doi.org/10.1056/NEJMoa2104840
Schultz NH, Sorvoll IH, Michelsen AE, et al. Thrombosis and Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination. N Engl J Med. 2021;384(22):2124-2130. DOI: https://doi.org/10.1056/NEJMoa2104882
Scully M, Singh D, Lown R, et al. Pathologic Antibodies to Platelet Factor 4 after ChAdOx1 nCoV-19 Vaccination. N Engl J Med. 2021;384(23):2202-2211. DOI: https://doi.org/10.1056/NEJMoa2105385
Nazy I, Sachs UJ, Arnold DM, et al. Recommendations for the clinical and laboratory diagnosis of VITT against COVID-19: Communication from the ISTH SSC Subcommittee on Platelet Immunology. J Thromb Haemost. 2021;19(6):1585-1588. DOI: https://doi.org/10.1111/jth.15341
Arepally GM, Ortel TL. Vaccine-induced immune thrombotic thrombocytopenia: what we know and do not know. Blood. 2021;138(4):293-298. DOI: https://doi.org/10.1182/blood.2021012152
Oldenburg J, Klamroth R, Langer F, et al. Diagnosis and Management of Vaccine-Related Thrombosis following AstraZeneca COVID-19 Vaccination: Guidance Statement from the GTH. Hamostaseologie. 2021;41(3):184-189. DOI: https://doi.org/10.1055/a-1469-7481
Gresele P, Marietta M, Ageno W, et al. Management of cerebral and splanchnic vein thrombosis associated with thrombocytopenia in subjects previously vaccinated with Vaxzevria (AstraZeneca): a position statement from the Italian Society for the Study of Haemostasis and Thrombosis (SISET). Blood Transfus. 2021;19(4):281-283.
Lindhoff-Last E, Schoenborn L, Piorkowski M, et al. Heterogeneity of Vaccine-Induced Immune Thrombotic Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination and Safety of Second Vaccination with BNT162b2. Thromb Haemost. 2022;122(2):304-307. DOI: https://doi.org/10.1055/a-1701-2926
. COVID-19 rapid guideline: vaccine-induced immune thrombocytopenia and thrombosis (VITT). London; 2022.
Thaler J, Jilma P, Samadi N, et al. Long-term follow-up after successful treatment of vaccine-induced prothrombotic immune thrombocytopenia. Thromb Res. 2021;207:126-130. DOI: https://doi.org/10.1016/j.thromres.2021.09.017
Gunther A, Bramer D, Pletz MW, et al. Complicated Long Term Vaccine Induced Thrombotic Immune Thrombocytopenia-A Case Report. Vaccines (Basel). 2021;9(11). DOI: https://doi.org/10.3390/vaccines9111344
Schonborn L, Thiele T, Kaderali L, Greinacher A. Decline in Pathogenic Antibodies over Time in VITT. N Engl J Med. 2021;385(19):1815-1816. DOI: https://doi.org/10.1056/NEJMc2112760
Craven B, Lester W, Boyce S, et al. Natural history of PF4 antibodies in vaccine-induced immune thrombocytopenia and thrombosis. Blood. 2022;139(16):2553-2560. DOI: https://doi.org/10.1182/blood.2021014684
Schonborn L, Thiele T, Kaderali L, et al. Most anti-PF4 antibodies in vaccine-induced immune thrombotic thrombocytopenia are transient. Blood. 2022;139(12):1903-1907. DOI: https://doi.org/10.1182/blood.2021014214
Cari L, Alhosseini MN, Fiore P, et al. Cardiovascular, neurological, and pulmonary events following vaccination with the BNT162b2, ChAdOx1 nCoV-19, and Ad26.COV2.S vaccines: An analysis of European data. J Autoimmun. 2021;125:102742. DOI: https://doi.org/10.1016/j.jaut.2021.102742
Pavord S, Scully M, Hunt BJ, et al. Clinical Features of Vaccine-Induced Immune Thrombocytopenia and Thrombosis. N Engl J Med. 2021;385(18):1680-1689. DOI: https://doi.org/10.1056/NEJMoa2109908
Lundstrom K, Barh D, Uhal BD, et al. COVID-19 Vaccines and Thrombosis-Roadblock or Dead-End Street? Biomolecules. 2021;11(7). DOI: https://doi.org/10.3390/biom11071020
How to Cite
1.
Barcella L, Ambaglio C, Gritti P, Schieppati F, Brusegan V, Sanga E, et al. Long-term persistence of high anti-PF4 antibodies titer in a challenging case of AZD1222 vaccine-induced thrombotic thrombocytopenia. Bleeding Thromb Vascul Biol [Internet]. 2023 Jun. 28 [cited 2026 Jan. 20];2(2). Available from: https://www.btvb.org/btvb/article/view/72
Copyright (c) 2023 The Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Similar Articles
- PO28 | Long term effectiveness and safety of venous thromboembolism with fondaparinux: data from the start registry , Bleeding, Thrombosis and Vascular Biology: Vol. 4 No. s1 (2025)
- Gualtiero Palareti, Paolo Prandoni, Cristina Legnani, Emilia Antonucci, Serena Zorzi, Alberto Tosetto, Lorenza Bertù, Sophie Testa, Vittorio Pengo, Walter Ageno, Ida Martinelli, Benilde Cosmi, Eugenio Bucherini, Daniela Poli, Rationale and design of a study on D-dimer use to stratify patients after a first unprovoked venous thromboembolism for their risk of recurrence: extended low-dose Apixaban given only to patients with positive D-dimer results , Bleeding, Thrombosis and Vascular Biology: Vol. 1 No. 1 (2022)
- Roberto Mario Santi, Annamaria Fulghesu, Ezio Zanon, Erica De Candia, Elvira Grandone, Giancarlo Di Renzo, Claudia Succu, Valentina Tosto, Vincenzina Bruni, Paolo Gresele, Diagnosis and management of abnormal uterine bleeding in adolescence , Bleeding, Thrombosis and Vascular Biology: Vol. 3 No. 1 (2024)
- Matteo Guarascio, Gerardo Nicola Pititto, Alessia Abenante, Marco Paolo Donadini, Distal deep vein thrombosis: is there a way out of this dark forest? , Bleeding, Thrombosis and Vascular Biology: Vol. 3 No. 2 (2024)
- Niccolò Bitto, Vincenzo La Mura, Anna Ludovica Fracanzani, Armando Tripodi, Is non-alcoholic fatty liver disease a prothrombotic risk factor? , Bleeding, Thrombosis and Vascular Biology: Vol. 2 No. 2 (2023)
- CO07 | Real word management of anticoagulant therapy in brain metastasis: moving toward a multidisciplinary approach in complex cases , Bleeding, Thrombosis and Vascular Biology: Vol. 4 No. s1 (2025)
- CS01 | Elucidating the evil relationship of metabolic dysfunction–associated fatty liver disease with cardiovascular comorbidities: the complex interplay among hypercoagulability, inflammation and liver fibrosis , Bleeding, Thrombosis and Vascular Biology: Vol. 4 No. s1 (2025)
- CO31 | Immune system profiling in FVIII-treated and emicizumab-treated pediatric HA patients , Bleeding, Thrombosis and Vascular Biology: Vol. 4 No. s1 (2025)
- Silvia Cardi, Filippo Catalani, Luca Valerio, Stefano Barco, From rare to aware: confronting Lemierre syndrome , Bleeding, Thrombosis and Vascular Biology: Vol. 3 No. 3 (2024)
- PO72 | Fondaparinux in patient with active tuberculosis , Bleeding, Thrombosis and Vascular Biology: Vol. 4 No. s1 (2025)
You may also start an advanced similarity search for this article.
Most read articles by the same author(s)
- Samantha Pasca, Cristina Santoro, Chiara Ambaglio, Marisanta Napolitano, Marta Milan, Letizia Natali, Silvia Nannizzi, Filippo Mori, Paolo Simioni, Ezio Zanon, Comparison among three different bleeding scores and the thrombin generation assay to assess the different hemorrhagic phenotypes in patients with FVII deficiency , Bleeding, Thrombosis and Vascular Biology: Vol. 1 No. 2 (2022)
- Daniela Poli, Walter Ageno, Emilia Antonucci, Salvatore Bradamante, Eugenio Bucherini, Paolo Chiarugi, Antonio Chistolini, Benilde Cosmi, Anna Falanga, Antonio Insana, Domenico Lione, Rosa Maria Lombardi, Giuseppe Malcangi, Rossella Marcucci, Giuliana Martini, Lucilla Masciocco, Carmelo Paparo, Daniele Pastori, Simona Pedrini, Vittorio Pengo, Pasquale Pignatelli, Andrea Toma, Sophie Testa, Gualtiero Palareti, Management of anticoagulation in atrial fibrillation patients in Italy: insight from the Atrial Fibrillation-Survey on Anticoagulated Patients Register (AF-START) , Bleeding, Thrombosis and Vascular Biology: Vol. 2 No. 2 (2023)
- Anna Falanga, Hugo Ten Cate, Bianca Rocca, How to manage antithrombotic treatments in thrombocytopenic patients with cancer. Comments on the European Haematology Association guidelines , Bleeding, Thrombosis and Vascular Biology: Vol. 2 No. 1 (2023)
- Anna Falanga, Benjamin Brenner, Alok A. Khorana, Welcome to the 12th International Conference on Thrombosis and Hemostasis Issues in Cancer! , Bleeding, Thrombosis and Vascular Biology: Vol. 3 No. s1 (2024)
- Eleonora Petito, Anna Maria Mezzasoma, Emanuela Falcinelli, Chiara Conti, Erica De Candia, Raimondo De Cristofaro, Silvia Sorrentino, Gian Marco Podda, Mariangela Scavone, Anna Falanga, Marina Marchetti, Luca Barcella, Stefania Basili, Lucia Stefanini, Andrea Boccatonda, Laura Contino, Patrizia Sciancalepore, Igor Florio, Egidio Imbalzano, Rossella Marcucci, Angela Rogolino, Patrizia Noris, Marta Panella, Rita Santoro, Maria Costanza Turi, Gaetano Vaudo, Rosa Curcio, Paolo Gresele, Persistence of functional anti-PF4 antibodies and neutrophil activation in vaccine-induced immune thrombotic thrombocytopenia , Bleeding, Thrombosis and Vascular Biology: Vol. 4 No. 3 (2025)
