Refractory vaccine-induced immune thrombotic thrombocytopenia (VITT) managed with delayed therapeutic plasma exchange (TPE)

J Clin Apher. 2022 Feb;37(1):117-121. doi: 10.1002/jca.21945. Epub 2021 Oct 21.


Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a newly described hematologic disorder, which presents as acute thrombocytopenia and thrombosis after administration of the ChAdOx1 nCov-19 (AstraZeneca) and Ad26.COV2.S (Johnson & Johnson) adenovirus-based vaccines against COVID-19. Due to positive assays for antibodies against platelet factor 4 (PF4), VITT is managed similarly to autoimmune heparin-induced thrombocytopenia (HIT) with intravenous immunoglobulin (IVIG) and non-heparin anticoagulation. We describe a case of VITT in a 50-year-old man with antecedent alcoholic cirrhosis who presented with platelets of 7 × 103 /μL and portal vein thrombosis 21 days following administration of the Ad26.COV2.S COVID-19 vaccine. The patient developed progressive thrombosis and persistent severe thrombocytopenia despite IVIG, rituximab and high-dose steroids and had persistent anti-PF4 antibodies over 30 days after his initial presentation. As such, delayed therapeutic plasma exchange (TPE) was pursued on day 32 of admission as salvage therapy, with a sustained improvement in his platelet count. Our case serves as proof-of-concept of the efficacy of TPE in VITT.

Keywords: coronavirus; platelet factor; thrombocytopenia; thrombosis; vaccines.

Publication types

  • Case Reports

MeSH terms

  • Ad26COVS1 / adverse effects*
  • Humans
  • Male
  • Middle Aged
  • Plasma Exchange / methods*
  • Platelet Count
  • Platelet Factor 4 / immunology
  • Purpura, Thrombocytopenic, Idiopathic / etiology
  • Purpura, Thrombocytopenic, Idiopathic / therapy*
  • Vaccination / adverse effects*


  • Ad26COVS1
  • PF4 protein, human
  • Platelet Factor 4