Vaccine-induced prothrombotic immune thrombocytopenia without thrombosis may not require immune modulatory therapy: A case report

Background: Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare complication of the ChAdOx1 nCoV-19 and Ad26.COV2.S COVID-19 vaccines. It presents most commonly with severe thrombocytopenia and thrombotic complications with extremely high D-dimer levels 5-30 days after vaccination. We report a patient who presented with mild thrombocytopenia and minimally elevated D-dimer levels without thrombosis, but who tested positive for antiplatelet factor 4 (PF4) platelet-activating antibodies on a PF4-enhanced serotonin-release assay.

Key clinical question: Is immunomodulation necessary in patients who present without thrombosis?

Clinical approach and conclusions: Treatment with rivaroxaban alone was followed by platelet normalization despite persistence of anti-PF4 antibodies. This case provides support that vaccination for COVID-19 can induce a broad, heterogeneous prothrombotic disorder characterized by anti-PF4 platelet-activating antibodies that shares features with classical heparin-induced thrombocytopenia (HIT) and autoimmune HIT syndromes and that immunomodulation may not be required in those without thrombosis.