Vaccine Induced Cerebro Venous Thrombosis with Thrombocytopenia (VITT)

Vaccine Induced Cerebro Venous Thrombosis with Thrombocytopenia (VITT) – A Case Report

Dominic Rodriguez*, R. M. Subbaih, T. Rajarajan, S. Srihari

Kauvery Hospital, Trichy-Tennur, India

*Correspondence: [email protected]

History and clinical presentation

A 24 years old female, M.Sc student, Covishield vaccine taken on 11.09.2021

Headache started around 20.09.2021 – 12 days post vaccine

H/o vomiting (+)

Referal doctor had noted severe thrombocytopenia

No significant PMH.

On Examination

Pallor (+)

No edema/wet purpura/LNP

PR: 58/min, BP: 120/90 mm Hg, Spo2: 98% on room air, RR: 20/min

CVS: S1 S2 (+), RS: NVBS, P/A: Soft

Fundus early papilledema BE/No venous pulsations

No other deficits.

Investigations

128-Multislice CT Scan Brain Plain Report (23.09.2021)

Hyperdense venous sinuses with cerebral edema. To consider CVT.

128-Multislice CT Scan Brain Plain Report (25.09.2021)

Superior sagittal sinus and right transverse sinus thrombosis with acute haemorrhagic infarct

Left frontal lobe and adjacent SAH, Mild diffuse cerebral edema.

128-Multislice CT Scan Brain Plain Report (26.09.2021)

CVT plain CT brain showed:

Hyperdense venous sinuses (CVT) with haemorrhagic, Infarct left frontoparietal regions and mass effect.

Compared with previous CT scan the mass effect is reduced.

128-Multislice CT Scan Brain Plain Report (04.10.2021)

Haemorrhagic infarct in left frontal lobe with adjacent edema and mass effect as described

Compared with previous CT scan dated 26.09.2021 there is mild reduction in mass effect.

Abdomen Scan Report Bedside (23.09.2021)

Mildly edematous gall bladder/Polycystic changes in both ovaries/Minimal ascites.

Diagnosis

VITT – Vaccine induced thrombosis with thrombocytopenia, acute CVT – sagittal sinus and right transverse sinus thrombosis, cerebral edema with left venous infarct and left frontal haemorrhage, acute right hemiparesis – recovering.

Treatment

Inj. Monocef	2 g	IV	0-0-1
Inj. Epsolin	100 mg	IV	1-1-1
Inj. Levipil	1 g	IV	1-0-1
Inj. Emeset	4 mg	IV	SOS
Inj. Pantop	40 mg	IV	1-0-1
Inj. Encorate chrono	500 mg	IV	1-1-1
Inj. IVIG	50 g	IV	OD over 5 hours
Inj. Dexa	4 mg	IV	1-0-0
Inj. Fondared	5 mg	S/C	0-1-0
Inj. 3% NACL	100 ml	IV	1-1-1-1-1-1
Tab. Folvite	5 mg		1-0-0
Tab. Dolo	650 mg		SOS
Tab. Xyzal			1-0-1
Tab. Encorate chrono	500 mg		1-0-1
Tab. Epsolin	100 mg		1-1-1
Tab. Pantop	40 mg		1-0-0
Tab. Levipil	500 mg		1-1-1
Tab. Cepodem	200 mg		1-0-1
Tab. Eliquis	5 mg		0-0-1
Tab. Brevipil	100 mg		1-0-1
Tab. Lonazep	0.5 mg		0-0-1
Tab. Shelcal	250 mg		1-0-1
Syp. Cremaffin plus	15 ml		1-0-1
Oral glycerol	15 ml		1-1-1

Course in The Hospital

23.09.2021 – Day 1

Arrival at casualty seen by hematologist, presented with CNS bleed

Severe thrombocytopenia – Initial diagnosis – Severe thrombocytopenia with CNS bleed

– ITP/CVT – Atypical features

– No significant purpura elsewhere

Symptoms onset 20.09.2021

Bilateral papilledema, CVT sagittal sinus + transverse sinus thrombus, Cerebral edema,Venous infarct with haemorrhage

At admission – IVIG (+)

– Dexa 40 mg IV – Started

Anti-coagulation withheld.

V – COVISHIELD

I – 12 days ON 11.09.2021

T – thrombosis – CVT – D-DIMER > 800 – fibrinogen decreased

T – thrombocytopenia 9000 cells/cu.mm

24.09.2021 – Day – 2

Prophylactic AED started

08:15 pm Right upper limb / lower limb transient weakness with recovery left adversive gaze

Two spells of seizure activity suspected transferred to ICU.

25.09.2021 – Day – 3

04:45 am Non-convulsive seizure 10 min

Speech (+), bilateral papilledema

Right UMN facial

Right distal (2/5) > proximal weakness (3/5)

Hand grip weak

Right lower limb weakness 4/5

Right upgoing plantar

Fonda 2.5 (24.09.2021 – 02:00 pm)

(Platelets – 26,000 cells/cu.mm).

25.09.2021 – Day 3

Acute left frontal haemorrhagic infarct with adjacent SAH, cerebral edema

Two doses IVIG complete (60) + (50)

Two days Dexa 40 completed by 24.09.2021

25.09.2021 – Plasma exchange – Started 3 FFP + 2 Albumin

Fonda – 5 mg on 25.09.2021 – Onwards.

26.09.2021 – Day – 4

Drop in sensorium – Platelet 28,000 cells/cu.mm

Right upper limb > lower limb weakness

CT repeated new haemorrhage left frontal.

Neurosurgical review

Anti edema measures Mannitol + Lasix

Plasma exchange continue

Fonda 5mg OD

04:45am Seizure, hypotension reverted AED, Levipil, Phenytoin, Encorate chrono

Poor prognosis

Ready for intubation.

27.09.2021 – Day – 5

05:30 am – Right upper limb/lower limb seizure < 1 min settled before treatment

Right UMN facial/Right upper limb response to pain/Left lower limb spontaneous movements

Bilateral papilledema, No bleed

Platelets: 60,000 cells/cu.mm.

28.09.2021 – Day – 6

Platelet – 1.3 L/Effects of CVT and haemorrhagic infarct/Completed Dexa 40-20-0, IVIG 60-50-0, Plasma exchange – 4.

29.09.2021 – Day – 7

Drowsiness

Effect of CVT

Platelets – 2.01L

Anti edema measures

No plasma exchange.

30.09.2021 – Day – 8

Sensorium better – Speech – Normal

Platelet – 3.51 L

Right UMN facial

Right upper limb paresis

No seizures

AED tapered, Dexa taper.

01.10.2021 – Day – 9

Platelet – 4.45 L, Fibrinogen 3.25 normal

3% NACL Q6H decreased

Speech – normal

CBD – Removed

Ward transfer done.

02.10.2021 – Day 10

Sensorium good

Speech – Normal

Right UMN facial

Right upper limb proximal 3/5, elbow – 2/5, distal – 1/2, handgrip – 0%.

Ambulated.

After platelet counts stablised, she was switched over to Apixaban 5 mg BD. She was observed for two more days and discharged in stable condition.

After initial treatment as for ITP till diagnosis was made, she was started on IV Dexa and IVIG which she completed over two days. She fulfilled criteria for VITT.

Since there was progressive deterioration clinically despite above treatment, plasma exchange was initiated and continued for four cycles. Fondaparinux was initiated as soon as platelet count increased above 20,000 cells/cu.mm.

Antiedema and AED dose was adjusted according to clinical status.

Very poor prognostic factors were noted on admission.

Significant CVT with cerebral edema and venous infarct with hemorrhage
High D-dimer (> 8000)
Low fibrinogen
Low platelets – 9000 cell/cu.mm (< 30,000 cells/cu.mm)

Patient improved with treatment. She was comanaged by Haematologist, Neurosurgeon, Nephrologist and Intensivists.

Condition at Discharge

General condition good

Vitals stable.

Advice on Discharge

Tab. Brevipil	100 mg	1-0-1 x 15 days
Tab. Eliquis	5 mg	1 (7am)-0-1 (7 pm) x 15 days
Tab. Pantocid	40 mg	1-0-0 x 15 days
Tab. Epsolin	100 mg	1-0-1 x 15 days
Tab. Folvite	5 mg	1-0-0 x 15 days
Tab. Xyzal		1-0-0 x 15 days
Tab. Shelcal	250	1-0-1 x 15 days
Tab. Encorate chrono	500 mg	1-0-1 x 15 days
Syp. Cremaffin	15 ml	1-0-1 x 15 days
Tab. Cepodem	200 mg	1-0-1 x 4 days
Tab. Lonazep	0.5 mg	(1) SOS for sleep
Oral glycerol	15 ml	1-1-1 x 5 days Then, 1-0-1 x 5 days and stop