Thrombosis and thrombocytopenia in COVID-19 and after COVID-19 vaccination

Thrombosis that occurs in coronavirus disease 19 (COVID-19) is a serious complication and a critical aspect of pathogenesis in the disease progression. Although thrombocytopenia is uncommon in the initial presentation, it may also reflect disease severity due to the ability of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to activate platelets. This occurs directly through the spike protein-angiotensin converting enzyme 2 (ACE2) interaction and indirectly by coagulation and inflammation activation. Dysregulation in both innate and adaptive immune systems is another critical factor that causes thrombosis and thrombocytopenia in COVID-19. Vaccination is the most potent and effective tool to mitigate COVID-19; however, rare side effects, namely vaccine-induced immune thrombotic thrombocytopenia (VITT)/thrombosis with thrombocytopenia syndrome (TTS) can occur following adenovirus-vectored vaccine administration. VITT/TTS is rare, and thrombocytopenia can be the clue to detect this serious complication. It is important to consider that thrombocytopenia and/or thromboembolism are not events limited to post-vaccination with vectored vaccine, but are also seen rarely after vaccination with other vaccines. Various conditions mimic VITT/TTS, and it is vital to achieving the correct diagnosis at an earlier stage. Antiplatelet factor 4 (PF4) antibody detection by the enzyme-linked immunosorbent assay (ELISA) is used for diagnosing VITT/TTS. However, false-positive rates also occur in vaccinated people, who do not show any thrombosis or thrombocytopenia. Vaccinated people with messenger RNA vaccine can show positive but low density and non-functional in terms of platelet aggregation, it is vital to check the optical density. If anti-PF4 ELISA is not available, discriminating other conditions such as antiphospholipid syndrome, thrombotic thrombocytopenic purpura, immune thrombocytopenic purpura, systemic lupus erythematosus, and hemophagocytic syndrome/hemophagocytic lymphohistiocytosis is critical when the patients show thrombosis with thrombocytopenia after COVID-19 vaccination.