Coronavirus infection, as well as vaccination against it with AstraZeneca (now called Vaxzevria) and Johnson & Johnson preparations are associated with cases of thrombosis. In both cases, there is also a specific type or course of the disease. While not all the mechanisms behind COVID-19-related thrombosis have been elucidated, many people would like to collect as much information as possible when deciding whether to vaccinate. Krzysztof Pujdak, MD, a specialist in internal medicine and cardiology from the Herford Clinic, shares his knowledge about the course, symptoms and possible remedies.
- Dr. Pujdak points out that thrombosis occurs in patients with COVID-19 – especially micro clots in the lungs are formed
- Blood clots after the COVID-19 vaccine can occur in both women and men, says the expert
- The doctor also presents the hypotheses of scientists who are trying to find the cause of thrombotic events in patients with COVID-19
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Monika Zieleniewska, MedTvoiLokony: What is the easiest way to define thrombosis?
Dr. Krzysztof Pujdak: Thrombosis is a condition in which there is intravascular coagulation of the blood. A clot forms that closes the lumen of a blood vessel – a vein or an artery. It is precisely depending on the type of blood vessel in which the clot has formed that we distinguish between venous and arterial thrombosis. Normally, the clot forms to close a wound or damaged blood vessel and stop blood from flowing. It is also possible that the thrombosis occurs for no obvious cause, such as activation of platelets or activation of clotting factors.
What can we say about the symptoms?
Symptoms vary depending on where the clot is forming. If it has formed in the veins of the lower leg, it is a typical lower limb vein thrombosis. We can recognize the disease by swelling, blue skin (cyanosis) and severe pain. If the clot has occurred in the pulmonary artery, which is quite common, it is called pulmonary embolism, manifested primarily by shortness of breath and chest pain.
- Editors recommend: Six symptoms of thrombosis you need to know
Does thrombosis associated with SARS-CoV-2 infection have any unique characteristics?
Thrombosis in COVID-19 infection can occur for two reasons.
First, patients tend to lie down, have a fever, sweat, and thus lose a lot of fluid that they do not compensate by drinking. This fact alone puts them at risk of slower blood flow and excessive clotting. Simply dehydration results in increasing blood density and a tendency for it to clot in the vessels. Therefore, anticoagulants are administered especially to patients with a more severe course of COVID-19.
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But a characteristic aspect of thrombosis with coronavirus infection is that micro-clots form in the lungs of these patients. This is shown by histopathological and imaging examinations. We do not observe similar micro-clots in classic pulmonary embolism, where a clot, e.g. in a leg vein, travels to the pulmonary artery and closes the vessel there. These micro pulmonary clots increase the inflammation associated with the infection and further deteriorate gas exchange. What is the cause of their formation? We don’t know yet, although some studies suggest that platelets become activated by antibodies our body produces in response to an infection. In other words, natural antibodies have so-called an affinity for platelets, they activate them, and they start sticking together.
So, is the thrombosis that occurs as a side effect of COVID-19 vaccination different?
The most commonly reported response to a vaccine is thrombosis in the brain’s veins, or venous sinus. It is a rare disease that affects approximately three to five people out of a million each year. Thus, counting, in Poland it would be about 160 cases a year. Since the COVID-19 vaccination campaign began, we have seen far more cases of cerebral vein thrombosis than might be expected. When such a rare disease is more common than usual, it is very easy to see a fluctuation.
I don’t see any particular reason why an isolated increase in the incidence of cerebral vein thrombosis should occur after coronavirus vaccination. Rather, I would suspect that if antibodies activate the blood’s clotting system, they do so not only in one type of blood vessel (here: the venous sinus of the brain), but throughout the body. Thus, more other types of thrombosis can be expected as well. However, reporting them is much more difficult because, especially in the elderly, symptoms are non-specific and may be attributed to age or comorbidities.
Some colleagues suspect that the vaccines caused thrombosis because they produced a large amount of antibodies, which is what the goal of vaccination is – to obtain high levels of antibodies in the blood without infection. If they have similar properties to natural antibodies, i.e. they stick together plaques, we have an increased risk of thrombosis.
Does this disease in vaccinated people have a classic course?
Low platelet counts are considered unique by some, but they are not. It is also possible in “normal” thrombosis, so it is not a value that allows a XNUMX% distinction. We know from scientific publications before the pandemic that massive thrombosis can also be associated with a drop in platelet levels and has nothing to do with either a viral infection or any vaccines. Although, for example, the authors of a recent article in the New England Journal of Medicine argue from the observation of five patients that this is a characteristic feature and even call it vaccine-induced immune thrombotic thrombocytopenia (VITT).
It is also worth mentioning the disease called HIT, which is characterized by a decrease in the level of platelets associated with heparin, i.e. a blood thinning agent. Heparin can trigger the formation of antibodies, simplifying the process can be compared to an allergy. Our antibodies cause the platelets to stick together to form clots, and their levels drop as a result. The stuck platelets cannot be seen in a standard blood test, but the antibodies that made them stick together can be detected.
So there is a link between the occurrence of thrombosis and the administration of the vaccine?
This is indicated by the frequency of thrombosis of the cerebral veins. A report on vaccine safety of April 9 this year. prepared by the Paul Erlich Institute (PEI), which is responsible for the approval and control of vaccines in Germany, calculates that the observed number of cases of cerebral vein thrombosis after vaccination in relation to the unvaccinated population is 23,57 for people aged 20-59 years. That is, in vaccinated people, the report does not specify which preparations, there are over 23 times more cases of this disease.
It is relatively easy to detect if it affects young and healthy people. It is different in older people, because it is easier to blame non-specific symptoms on general malaise and comorbidities. In addition, in Germany, the elderly were vaccinated mainly with Pfizer and the younger ones with AstraZeneka, so it is difficult to make a comparison.
- See also: Watch out for these symptoms after AstraZeneka. These are signs of a thrombosis
It is said that thrombosis is more common in women. Is it reported to be related to the use of birth control pills?
Not necessarily. Even without the pills, the risk of thrombosis in women is about 2,5 times higher than in men. It has to do with female hormones. And if the natural hormone balance is influenced by birth control pills, the risk of thrombosis increases even more. Moreover, the risk of thrombosis is increased in congenital thrombophilias, i.e. genetically determined conditions in which, for example, due to mutations of genes encoding proteins involved in blood clotting, they do not function properly.
Smoking is an additional risk factor, as it activates platelets and disrupts the functions of the vascular endothelium, i.e. the inner layer of blood vessels that also affect clotting. Besides obesity, a sedentary lifestyle.
Venous sinus thrombosis in the brain also affects healthy men vaccinated with the coronavirus. In a vaccine safety report issued by the German regulator, we read that men between the ages of 20 and 60 had a 27 times higher risk of contracting the disease. This group was vaccinated with AstraZeneca.
Generally, regardless of the type of vaccine, 70 – 80 percent. all reported post-vaccination complications, mild and severe, were in women. However, it should not be forgotten that the majority of people vaccinated in Germany were women (64%).
How are cases of cerebral vein thrombosis explained in men?
Nobody knows that. I think it makes sense to explain that antibodies to the SARS-CoV-2 virus have something to do with platelets and activate clotting. It doesn’t matter if they are made artificially by a vaccine or by infection. But we do not have any obvious scientific evidence to support this hypothesis.
What are the most characteristic symptoms after receiving the vaccine that should attract our attention?
Headache that lasts for a long time and does not go away with anti-inflammatory or analgesic drugs, especially when associated with neurological disorders. I mean, for example, speech and movement disorders, or unilateral paresis, numbness of the arm or leg, sometimes paralysis of the cranial nerves, e.g. a hanging corner of the mouth.
I would like to add that in the abovementioned report of the Paul Erlich Institute it is written to pay attention to other symptoms, such as dyspnoea, chest pain, swelling of the upper or lower limb. These are the classic symptoms of venous thrombosis associated with pulmonary embolism.
The report mentions 430 reported cases of post-vaccination thrombosis, in addition to highlighting the possibility of a high number of unreported cases. Since the vaccine activates clotting, it would be illogical for it to be confined to the venous sinus in the brain, so it is important to pay attention to all possible symptoms of a bleeding disorder.
How should we respond?
Better to be proactive, that is, be safe than sorry. All COVID-19 patients should drink a lot, of course paying attention to the indications for fluid intake in comorbidities, because fluid intake must be adjusted, e.g. to heart failure. In general, you need to compensate for the loss of fluid resulting from the increased sweating.
In patients with a more severe course of COVID-19, doctors should consider anticoagulant treatment, such as heparin. Low-dose aspirin drugs are not strong enough to inhibit the high aggregation or sticking of platelets that can occur in COVID-19.
So in this case, heparin won’t hurt?
No, there is ample evidence to suggest that anticoagulation treatment in patients with a severe course of COVID-19 improves the prognosis of recovery.
- Venous thrombosis – testing for genetic diseases in different genotypes is a test that we can perform to confirm or rule out thrombophilia.
This may interest you:
- Canada: Two cases of post-vaccination thrombosis in one week
- “A stone from the heart”, “I breathed a sigh of relief”. They come here for vaccinations from all over Poland
- How many people in Poland died or had thrombosis after vaccination? New data
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