Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Platelet factor 4, Protein S, Thrombocytopenia, Venogram, Visceral venous thrombosis
Clinical narrative: THROMBOCYTOPENIA; SPLANCHNIC THROMBOSIS; This spontaneous report was received from literature: et al. Thrombocytopenia and splanchnic thrombosis after Ad26.COV2.S vaccination successfully treated with transjugular intrahepatic portosystemic shunting and thrombectomy American journal of hematology 2021 no pagination. This report concerned a 24 year old male. The patient's weight, height, and medical history were not reported. A 24-year-old previously healthy male, presented with 10-day history of severe abdominal pain, nausea, vomiting, and decreased oral intake. He had been seen at urgent care 2 days earlier for similar symptoms, treated for presumed gastritis with belladonna alkaloids, phenobarbital, antacid, and viscous lidocaine, and had moderate improvement. He received the Ad26.COV2.S vaccine 11 days prior to onset of symptoms.  He had diffuse abdominal tenderness and mild thrombocytopenia (66,000 /µl), leukocytosis (11,400 /µl), elevated D-dimer (>5250 ng/ml) with normal hemoglobin 13.8 g/dl. That evening, he had worsening abdominal pain, maroon-colored emesis and drop in hemoglobin to 7.9 g/dl. He was transferred to the intensive care unit. Testing for SARS-CoV-2 was negative. Contrast enhanced computerized tomography (CT) showed extensive occlusive thrombosis of the portal, superior mesenteric (SMV), and splenic veins with severe bowel wall thickening concerning for venous ischemia. Brain magnetic resonance venography was negative for cerebral venous thrombosis. He was treated with heparin for 20 h and then bivalirudin due to concern for vaccine-induced thrombotic thrombocytopenia (VITT). He had esophagogastroduodenoscopy (EGD) on hospital Day 3 for hematemesis showing impressive congestive gastropathy, but no evidence of Mallory-Weiss tear, gastritis, ulcer or carcinoma. His platelet count ranged from 66,000/µl to 82,000/µl and he continued bivalirudin. Repeat abdominal imaging on Day 4 showed worsening of his extensive portal, SMV and splenic vein thrombosis, worsening small bowel thickening, and splenic hypoenhancement suggesting infarction.  The patient was transferred for evaluation by radiology. Patient was administered intravenous immunoglobulin (IVIG) 1 g/kg on Days 5 and 6. After multidisciplinary discussion, doctors proceeded with transjugular intrahepatic portosystemic shunt (TIPS) and thrombectomy to reduce the risk of further bowel ischemia and long-term complications of portal hypertension. Doctors used intravascular ultrasound guidance with intracardiac echocardiography to gain access to the thrombosed portal venous system. They advanced, with some difficulty, a wire through the thrombosed portal vein and SMV into the patent distal SMV tributaries and deployed a 10 mm diameter TIPS stent (Gore Viatorr). Doctors suctioned clot from the portal vein and SMV with an Inari FlowTriever 16 and used the AngioJet thrombectomy device with 3 milligrams of tissue plasminogen activator to clear the splenic vein. The following morning, the patient had complete resolution of abdominal pain. Post-procedure contrast enhanced CT scan demonstrated patency of the TIPS, SMV, and splenic veins, normal enhancement of the spleen and reduced small bowel wall thickening. The patient was evaluated by surgery as one loop of bowel had persistent wall thickening; but was managed non-operatively. The diet was advanced without any further pain. No other causes of thrombophilia were identified including Factor V Leiden, prothrombin gene G20210A, JAK2 V617F mutations, decreased protein C and S, antithrombin and ADAMTS13 activity or elevated homocysteine. Both free protein S (67%, reference range of 74146) and factor VII activity (49, reference range 50%129% were mildly decreased, likely from liver synthetic dysfunction. Patient had no evidence of a lupus anticoagulant or anticardiolipin, and beta-2-glycoprotein antibodies. Testing for heparin-induced thrombocytopenia by latex immunoassay was negative twice (<0.600 U/ml, <1 negative) and serotonin release assay was negative. However, he had evidence of anti-PF4 IgG antibodies by ELISA (OD 2.47, >0.5 positive), confirming vaccine-induced thrombotic thrombocytopenia. On Day 12, bivalirudin was stopped and patient started apixaban 5 mg every 12 h. Platelet count was 292,000/µl. On Day 13, he was discharged home. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The outcome of the thrombocytopenia and splanchnic thrombosis was not reported. This report was serious (Life Threatening and Hospitalization Caused / Prolonged).; Sender's Comments: V0: This is a spontaneous report received from literature concerning a 24 year old male, unknown ethnicity, who was noted to have thrombocytopenia and splanchnic thrombosis 11 days after receiving the Janssen Covid-19 vaccine. The patient's weight, height, and medical history were not reported. Patient presented with abdominal pain, nausea, vomiting, and decreased oral intake. He was presumed to have gastritis and treatment was started. Abdominal tenderness became diffused and patient was worked up on. The laboratory results included: mild thrombocytopenia (ranging from 66,000/µl to 82,000/µl), leukocytosis (11,400 /µl), elevated D-dimer (>5250 ng/ml), and negative SARS-CoV-2 test. Diagnostic imaging results included: contrast enhanced computerized tomography (CT) showed extensive occlusive thrombosis of the portal, superior mesenteric (SMV), and splenic veins; brain magnetic resonance venography was negative for cerebral venous thrombosis. Patient also had esophagogastroduodenoscopy (EGD) which showed congestive gastropathy. No other causes of thrombophilia identified. Patient had no evidence of a lupus anticoagulant or anticardiolipin, and beta-2-glycoprotein antibodies. Testing for heparin-induced thrombocytopenia by latex immunoassay was negative twice (<0.600 U/ml, <1 negative). Serotonin release assay was negative. However, he had evidence of anti-PF4 IgG antibodies by ELISA (OD 2.47, >0.5 positive), confirming vaccine-induced thrombotic thrombocytopenia. He was given IVIG and started with heparin but shifted to bivalirudin. Transjugular intrahepatic portosystemic shunt (TIPS) and thrombectomy were done.  Based on evolving knowledge of Thrombosis with Thrombocytopenia Syndrome (TTS, per definition from Brighton Collaboration-BC Level 1), the low platelet count and temporal relationship to vaccination, the event(s) is/are assessed to have a plausible relationship with vaccination.