Sex: F
Vaccine: COVID19, COVID19
Symptoms: Cerebral venous sinus thrombosis, Computerised tomogram, Computerised tomogram head, Disseminated intravascular coagulation, Fibrin D dimer
Clinical narrative: DISSEMINATED INTRAVASCULAR COAGULATION; HEMORRHAGIC STROKE; CEREBRAL VENOUS SINUS THROMBOSIS; SEVERE THROMBOCYTOPENIA; MILD ANEMIA; HEPATIC VEIN THROMBOSIS; SPLENIC VEIN THROMBOSIS; SPLANCHNIC VEIN THROMBOSIS; This spontaneous report was received from physician via literature article  The patient is a 48-year-old woman with unremarkable past medical history who received Ad26.COV2.S vaccine (date unknown).  She developed malaise and abdominal pain 11 days following vaccination and presented to an emergency room 3 days later. Evaluation revealed mild anemia and severe thrombocytopenia (platelet count, 13,000 per cubic millimeter). Peripheral blood smear confirmed marked reduction in platelet count with occasional schistocytes. Other laboratory evaluation showed hypofibrinogenemia (89 mg/dL), prolonged activated partial thromboplastin time (41 sec), and marked elevation in D-Dimer (117.5 mg/L), indicating disseminated intravascular coagulation. Nasopharyngeal swab tested negative for SARS-CoV2 by RT-PCR (polymerase chain reaction).  CT (computerised tomogram) imaging of abdomen/pelvis which showed extensive splanchnic vein thrombosis. The patient developed a new onset headache, and head CT revealed cerebral venous sinus thrombosis (CVST) involving right transverse/straight sinus. Initially, the hospital was not aware that the patient was recently vaccinated, and initiated treatment with unfractionated heparin.  She developed progressive thrombosis with hemorrhagic stroke evident by MRI(magnetic resonance imagin)/MRV of brain while on heparin, with repeat CT angiography showed new thrombus involving right hepatic and splenic veins.    Upon further inquiry it was noted she had received the Ad26.COV2.S vaccine 14 days before symptom onset. New laboratory evaluation revealed negative anti-PF4/heparin antibodies by latex-enhanced immunoassay (results of a PF4 (Platelet factor 4)/polyanion ELISA are pending). The patient was treated with intravenous immunoglobulin (1 gm/kg times 2 days), and anticoagulation switched to argatroban.  Her platelet count increase from 30,000 to 145,000 over 5 days. She remains critically ill at time of last report.   The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The outcome of the mild anemia, severe thrombocytopenia, disseminated intravascular coagulation, cerebral venous sinus thrombosis, hemorrhagic stroke, hepatic vein thrombosis, splenic vein thrombosis and splanchnic vein thrombosis was not reported. This report was serious (Hospitalization, Other Medically Important Condition, and Life Threatening).; Sender's Comments: V0: This case involves a 48-year old woman who developed splanchnic vein thrombosis / cerebral venous sinus thrombosis (CVST) and thrombocytopenia 14 days following administration of Ad26.COV2.S vaccine.  Initial presentation also included hypofibrinogenemia and markedly elevated D-Dimer.  Anti-PF4/heparin antibody testing is negative by latex-enhanced immunoassay (ELISA test pending).  The CVST progressed while on treatment with heparin (before vaccination status was known), with secondary hemorrhagic stroke.  Anticoagulation was switched to argatroban, and platelet count increased following treatment with intravenous immunoglobulin. The case appears consistent with a possible immune-mediated process resulting in a hypercoagulable state.