Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2021 Jun 22;5(12):2569-2574.
doi: 10.1182/bloodadvances.2021004904.

A case of thrombocytopenia and multiple thromboses after vaccination with ChAdOx1 nCoV-19 against SARS-CoV-2

Anne Louise Tølbøll Sørensen  1 , Magalie Rolland  2 , Jacob Hartmann  3 , Zitta Barrella Harboe  2   4 , Casper Roed  2 , Tomas Ø Jensen  2 , Lilian Kolte  2 , Daniel El Fassi  1   4 , Jens Hillingsø  5 , Aneta Radziwon-Balicka  6 , Robert Sebastian Soyka  7 , Klaus Hansen  8 , Nikolai Kirkby  9 , Jens P Goetze  10 , Mikkel Gybel-Brask  11 , Eva Birgitte Leinøe  1 , Anne-Mette Hvas  6   12 , Peter Kampmann  1 , Jakob Stensballe  11   13
Affiliations
Case Reports

A case of thrombocytopenia and multiple thromboses after vaccination with ChAdOx1 nCoV-19 against SARS-CoV-2

Anne Louise Tølbøll Sørensen et al. Blood Adv. .

Abstract

Recently, reports of severe thromboses, thrombocytopenia, and hemorrhage in persons vaccinated with the chimpanzee adenovirus-vectored vaccine (ChAdOx1 nCoV-19, AZD1222, Vaxzevria; Oxford/AstraZeneca) against severe acute respiratory syndrome coronavirus 2 have emerged. We describe an otherwise healthy 30-year-old woman who developed thrombocytopenia, ecchymosis, portal vein thrombosis, and cerebral venous sinus thrombosis the second week after she received the ChAdOx1 nCoV-19 vaccine. Extensive diagnostic workup for thrombosis predispositions showed heterozygosity for the prothrombin mutation, but no evidence of myeloproliferative neoplasia or infectious or autoimmune diseases. Her only temporary risk factor was long-term use of oral contraceptive pills (OCPs). Although both the prothrombin mutation and use of OCPs predispose to portal and cerebral vein thrombosis, the occurrence of multiple thromboses within a short time and the associated pattern of thrombocytopenia and consumption coagulopathy are highly unusual. A maximum 4T heparin-induced thrombocytopenia (HIT) score and a positive immunoassay for anti-platelet factor 4/heparin antibodies identified autoimmune HIT as a potential pathogenic mechanism. Although causality has not been established, our case emphasizes the importance of clinical awareness. Further studies of this potentially new clinical entity have suggested that it should be regarded as a vaccine-induced immune thrombotic thrombocytopenia.

PubMed Disclaimer

Conflict of interest statement

Conflict-of-interest disclosure: A.L.T.S. is a former employee of Novo Nordisk Biopharm and has received honoraria for lecture from Takeda and advisory board honoraria from SOBI (both not related to the present case). Z.B.H. received an unrestricted research grant from the Independent Research Fund Denmark (not related to the present case), and received travel expenses for attending a medical conference from Pfizer. C.R. has received travel expenses for attending medical conferences from Pfizer and MSD. L.K. has received an honorarium for a lecture on pneumococcal disease from MSD. J.H. receives consulting fees for Novo Nordisk on drug delivery. E.B.L. has received honoraria from Amgen for a lecture on immune thrombocytopenia (not related to present case). A.-M.H. has received an unrestricted research grant from CSL Behring (not related to the present case) and has received honoraria for lectures from CSL Behring, Bayer, Astellas, and Boehringer-Ingelheim. P.K. has received honoraria for lectures from uniQure and Takeda and travel expenses for attendance at medical conferences from uniQure. The remaining authors declare no competing financial interests.

Figures

Figure 1.
Figure 1.
Timeline from presentation of first symptoms 8 days after vaccination with the ChAdOx1 nCoV-19 vaccine to outpatient postvaccination follow-up day 35. Serial coagulation test results are shown: platelet counts, D-dimer, and fibrinogen. Time points for the result of the anti-PF4 antibody test and key clinical events, including timing of thrombosis events and changes in anticoagulant treatment, are also shown. ED, emergency department; MRI, magnetic resonance imaging; ELISA, enzyme-linked immunosorbent assay; HIPA, heparin-induced platelet activation; FEU, fibrinogen equivalent units.
See this image and copyright information in PMC

References

    1. Voysey M, Clemens SAC, Madhi SA, et al. ; Oxford COVID Vaccine Trial Group. Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. Lancet. 2021;397(10269):99-111. - PMC - PubMed
    1. European Medicines Agency. COVID-19 Vaccine AstraZeneca: benefits still outweigh the risks despite possible link to rare blood clots with low blood platelets. Available at: https://www.ema.europa.eu/en/news/covid-19-vaccine-astrazeneca-benefits-...
    1. Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A.. Evaluation of pretest clinical score (4 T’s) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost. 2006;4(4):759-765. - PubMed
    1. Greinacher A, Selleng K, Warkentin TE.. Autoimmune heparin-induced thrombocytopenia. J Thromb Haemost. 2017;15(11):2099-2114. - PubMed
    1. Juhl D, Eichler P, Lubenow N, Strobel U, Wessel A, Greinacher A.. Incidence and clinical significance of anti-PF4/heparin antibodies of the IgG, IgM, and IgA class in 755 consecutive patient samples referred for diagnostic testing for heparin-induced thrombocytopenia. Eur J Haematol. 2006;76(5):420-426. - PubMed

Publication types