The clinical and laboratory diagnosis of vaccine-induced immune thrombotic thrombocytopenia

Abstract

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare but serious adverse syndrome occurring 5 to 30 days after adenoviral vector COVID-19 vaccination. Therefore, a practical evaluation of clinical assessments and laboratory testing for VITT is needed to prevent significant adverse outcomes as the global use of adenoviral vector vaccines continues. We received the clinical information and blood samples of 156 patients in Canada with a suspected diagnosis of VITT between April and July 2021. The performance characteristics of various diagnostic laboratory tests were evaluated against the platelet factor 4 (PF4)-14C-serotonin release assay (SRA) including a commercial anti-PF4/heparin immunoglobulin G (IgG)/IgA/IgM enzyme immunoassay (EIA, PF4 Enhanced; Immucor), in-house IgG-specific anti-PF4 and anti-PF4/heparin-EIAs, the standard SRA, and the PF4/heparin-SRA. Of those, 43 (27.6%) had serologically confirmed VITT-positive based on a positive PF4-SRA result and 113 (72.4%) were VITT-negative. The commercial anti-PF4/heparin EIA, the in-house anti-PF4-EIA, and anti-PF4/heparin-EIA were positive for all 43 VITT-confirmed samples (100% sensitivity) with a few false-positive results (mean specificity, 95.6%). These immunoassays had specificities of 95.6% (95% confidence interval [CI], 90.0-98.6), 96.5% (95% CI, 91.2-99.0), and 97.4% (95% CI, 92.4-99.5), respectively. Functional tests, including the standard SRA and PF4/heparin-SRA, had high specificities (100%), but poor sensitivities for VITT (16.7% [95% CI, 7.0-31.4]; and 46.2% [95% CI, 26.6-66.6], respectively). These findings suggest EIA assays that can directly detect antibodies to PF4 or PF4/heparin have excellent performance characteristics and may be useful as a diagnostic test if the F4-SRA is unavailable.

Graphical abstract

Figure 1.

Results of 3 immunoassays for VITT antibody detection. Commercial Immucor IgG/A/M anti-PF4/heparin EIA, and the in-house IgG-specific anti-PF4-EIA and anti-PF4/heparin-EIA results for all VITT-positive patients (n = 43; PF4-SRA, ≥20% ¹⁴C-serotonin release) and VITT-negative patients (n = 113; PF4-SRA, ≤20% ¹⁴C-serotonin release). An OD_405nm ≥ 0.40 is considered positive for anti-PF4 and anti-PF4/heparin antibodies in the Immucor IgG/A/M-EIA, shown as a red dotted line. An OD_405nm ≥ 0.45 is considered positive for anti-PF4 and anti-PF4/heparin antibodies in the in-house IgG specific PF4/heparin-EIA and PF4-EIA, also shown as a red dotted line.