Case report

Pulmonary embolism, transient ischaemic attack and 
thrombocytopenia after the Johnson & Johnson 
COVID-19 vaccine
Bilal Malik      ,1 Atefeh Kalantary,1 Kamal Rikabi,1 Arvind Kunadi2 

SUMMARY
As with past illnesses, an approach has been taken 
to vaccinate the population and halt the spread of 
COVID-19. On 13 April 2021, the US Food and Drug 
Administration called for a halt in the administration 
of the Johnson & Johnson (J&J) COVID-19 vaccine due 
to reports of thrombosis and thrombocytopenia being 
associated with vaccination. We present the case of 
a 43- year- old woman with a history of dyslipidaemia, 
depression, gastro- oesophageal reflux disease and 
obesity presenting with dyspnoea, headache and light 
headedness of 3 days’ duration. Ten days prior, she had 
received the J&J COVID-19 vaccine. She was found to 
have thrombocytopenia, elevated D- dimers, pulmonary 
emboli and presented 1 day after discharge with an 
arterial clot despite being on apixaban. Six other US- 
based cases of venous thrombotic events are being 
reviewed at present. Patients should be informed of the 
possibility of such events to provide informed consent.

BACKGROUND
On  12  April  2021,  the  Advisory  Commission 
on  Immunisation  Practices  (ACIP)  convened  to 
review  the  serious  complications  experienced  by 
six  patients  after  taking  the  Johnson  and  Johnson 
(J&J)  COVID-19  vaccination.  The  US  Food  and 
Drug  Administration  (FDA)  and  Centers  for 
Disease  Control  and  Prevention  (CDC)  jointly 
recommended a pause in the utilisation of the J&J 
vaccine pending further review.1 2 Interestingly, all 
six  patients  who  were  reported  in  the  above  cita-
tions had experienced cerebral venous sinus throm-
bosis  (CVST),  were  Caucasian  females  between 
the  ages  of  18  and  40  years  old,  and  were  found 
to  be  thrombocytopenic.2  3  Scully  et  al4  identified 
a  similar  trend  with  the  AstraZeneca  COVID-19 
vaccine,  whereby  23  patients  developed  CVST 
and  thrombocytopenia  within  1 week  of  vaccine 
uptake.4 During the evaluation of the AstraZeneca 
vaccine,  the  UK  Medicines  and  Healthcare  Prod-
ucts  Regulatory  Agency  (MHRA)  and  European 
Medicine  Agency  (EMA)  both  concluded  that  the 
thrombotic  risk  associated  with  vaccine  uptake 
was not elevated relative to the risk in the general 
population.4

Despite  the  acknowledgement  of  the  possibility 
of  thrombotic  events  as  rare  adverse  events  asso-
ciated with such vaccines, the above agencies have 
emphasised the benefits outweighing the risks given 
the  COVID-19  pandemic.4  Similar  conclusions 
have been drawn based on the US FDA, CDC and 

EMA  assessments  on  20–25  April  2021,  where 
they concluded that benefits outweighed the risks, 
warnings were to be added to the product informa-
tion for the vaccines, and administration was to be 
resumed.5–7  Additionally,  the  manufacturer  of  the 
J&J  vaccine  has  also  released  a  direct  response  to 
the  authors  of  the  case  report  titled,  ‘Thrombotic 
Thrombocytopenia  after  Ad26.COV2.S  Vaccina-
tion’,8  stating  that  they  did  have  a  single  case  of 
CVST  and  thrombocytopenia  during  their  clinical 
trial programme in which 50 000 patients received 
the  active  vaccine.9  The  adverse  event  was  inves-
tigated  at  that  point  in  time  as  well,  resulting  in 
no  explicit  causal  relationship  being  established.9 
Of  note,  however,  was  the  platelet  factor  4  (PF4) 
positivity in the patient in question, which was also 
identified in other patients experiencing this entity. 
The authors also made a point of highlighting the 
incidence  of  CVST  as  rare  (0.2–1.57  per  100 000 
person- years)  and  the  cases  occurring  with  the 
AstraZeneca  vaccine  as  ‘within  the  range  of  the 
background incidence of CVST’.9

Today,  we  present  the  case  of  a  43- year- old 
Caucasian woman with no known history or predis-
position for thrombosis. She had received the J&J 
vaccine  and  was  discovered  to  have  thrombocyto-
penia and a pulmonary embolism (PE) on CT scan-
ning 10 days later. She was initially thought to have 
CVST  based  on  a  CT  angiogram  of  the  head  and 
neck  performed  due  to  complaints  of  headaches 
and  light  headedness.  This  was  later  clarified  to 
be  a  chorionic  granulation  as  evidenced  on  MRI 
of  the  head  and  neck.  She  was  managed  in  the 
intensive  care  unit  with  intravenous  immunoglob-
ulin (IVIG) and fondaparinux (Arixtra). Ultimately, 
she was discharged on oral anticoagulation with a 
non- heparin  agent  but  did  return  1 day  later  due 
to a suspected stroke- like episode where she expe-
rienced  facial  and  right  upper  limb  numbness  and 
tingling. The cases mentioned in the ACIP, FDA and 
CDC reports all experienced CVST and thrombo-
cytopenia. This is the first case, to the best of our 
knowledge,  with  a  J&J  vaccine  recipient  devel-
oping  PE,  thrombocytopenia,  and  a  subsequent 
arterial clot despite being on anticoagulation. With 
an incidence of 0.87 per million vaccines adminis-
tered, based on available data, the question of how 
concerning these findings arises in an already uncer-
tain landscape.

CASE PRESENTATION
Our patient is a 43- year- old Caucasian woman with 
a  history  of  hyperlipidaemia,  anxiety,  depression, 

1

B
M
J
 
C
a
s
e
R
e
p

 

:
 
f
i
r
s
t
 

p
u
b

l
i

s
h
e
d
a
s
 

 

.

1
0
1
1
3
6

/

b
c
r
-
2
0
2
1
-
2
4
3
9
7
5
 
o
n
 
1
4
 
J
u
y
 
2
0
2
1
.
 

l

l

D
o
w
n
o
a
d
e
d
 
f
r
o
m
 
h
t
t
p
:
/
/
c
a
s
e
r
e
p
o
r
t
s
.
b
m

j
.
c
o
m

/
 
o
n
 
O
c
t
o
b
e
r
 
4
,
 
2
0
2
2
 
b
y
 
g
u
e
s
t
.
 

 

t

P
r
o
e
c
t
e
d
b
y
 
c
o
p
y
r
i
g
h
t
.

1Internal Medicine, McLaren 
Health Care Corp/ MSU, Flint, 
Michigan, USA
2Nephrology/ Internal Medicine, 
McLaren Health Care Corp/ 
MSU, Flint, Michigan, USA

Correspondence to
Dr Bilal Malik;  
 Bilal. Malik@ mclaren. org

Accepted 25 June 2021

© BMJ Publishing Group 
Limited 2021. No commercial 
re- use. See rights and 
permissions. Published by BMJ.

To cite: Malik B, Kalantary A, 
Rikabi K, et al. BMJ Case 
Rep 2021;14:e243975. 
doi:10.1136/bcr-2021-
243975

Malik B, et al. BMJ Case Rep 2021;14:e243975. doi:10.1136/bcr-2021-243975

Case report

Figure 1  Left (A): CT angiography of the head and neck 
demonstrating a filling defect in the confluence of the venous sinus. 
Right (B): MRI of the brain demonstrating the same, further delineating 
the lesion as an arachnoid granulation. Yellow arrows: Identify the 
lesion in both images.

obesity, obstructive sleep apnoea and gastro- oesophageal reflux 
disease  who  presented  to  the  emergency  department  with 
a  3- day  history  of  generalised  headache,  fever,  body  aches, 
chills,  mild  dyspnoea  and  lightheadedness.  Approximately  10 
days before her presentation, she received the J&J COVID-19 
vaccine. She reported a maximum temperature of 103.8°F. She 
decided to seek evaluation due to the progressive nature of her 
headache,  which  had  become  unbearable  to  the  patient  at  the 
time  of  her  evaluation.  CT  angiography  of  her  head  and  neck 
was performed and significant for a low- density rounded filling 
defect  in  the  venous  sinus  confluence,  worrisome  for  CVST 
(figure  1A).  Complete  blood  count  (CBC)  and  basic  metabolic 
profile  (BMP)  were  performed  at  this  time  and  significant  for 
thrombocytopenia  with  platelets  of  27000×109/L.  COVID-19 
testing was negative. At this point, the patient was transferred to 
our facility for further workup and management.

On  arrival,  an  MRI  of  the  head  was  performed  for  further 
evaluation  of  the  filling  defect.  MRI  revealed  a  focal  filling 
defect in the region of the sinus confluence, characterising it as 
the typical appearance for an arachnoid granulation (figure 1B). 
No intracranial haemorrhage or mass lesion was present on MRI. 
Vital signs were stable with a blood pressure of 124/80 mm Hg, 
heart rate of 65 beats/min, a temperature of 37.9oC, a respira-
tory rate of 20 breaths/min and an oxygen saturation of 96% on 
room air. On respiratory examination, the patient had good air 
entry  bilaterally  with  no  wheezing  throughout  the  lung  fields 
and no crackles at the lung bases. Neurological examination was 
within  normal  limits,  with  no  focal  motor  or  sensory  deficits. 
Further laboratory evaluation was performed, and her D- dimer 
came back elevated at 35.20 mg/L. She denied any use of nico-
tine  products  or  hormonal  medications  (hormone  replacement 
therapy or oral contraceptive pills). Doppler images of bilateral 
upper and lower extremities were negative for any evidence of 
deep vein thrombosis (DVT). In conjunction with her dyspnoea, 
her  elevated  D- dimer  prompted  evaluation  for  a  PE  with  CT 
pulmonary angiogram, which turned out positive for right upper 
lobe, right lower lobe, and left lower lobe lobar and segmental 
pulmonary emboli (figure 2).

Haematology was consulted for further workup of an under-
lying hypercoagulable condition. The patient denied any history 
of having experienced a blood clot in the past or any significant 
contributory  family  history.  Given  the  call  for  pausing  admin-
istration  of  the  J&J  vaccine  just  1 week  prior  and  the  recent 
thrombotic  complications  with  the  AstraZeneca  vaccine,  the 
patient was given a dose of 60 g of IVIG and started on 7.5 mg 

Figure 2  CT angiography of the lungs. (A, C) Right pulmonary artery 
demonstrating emboli. (B, D) Left pulmonary artery demonstrating 
emboli. Yellow arrows point out filling defects (emboli) in each 
respective area.

fioricet 

of  subcutaneous  fondaparinux  daily  thereafter,  with  partic-
ular caution to avoid heparin products. Her pain was managed 
(butalbital- acetaminophen- caffeine) 
with  as- needed 
and scheduled topiramate. Table 1 displays the results from an 
extensive  haematologic  workup.  Of  note,  she  was  ultimately 
positive for PF4 antibody, anti- nuclear antibody (ANA) and slide 
review/peripheral  smear  significant  for  thrombocytopenia  with 
increased  mean  platelet  volume  and  platelet  insufficiency.  She 
received  two  total  doses  of  60  g  of  IVIG,  which  did  success-
fully improve her platelet count to 132×103/ μL over her 6- day 
admission.  On  discharge,  she  was  prescribed  apixaban  5 mg 
orally,  two  times  per  day  for  anticoagulation,  and  fioricet  and 
topiramate for cephalalgia. Ultimately, there was no alternative 
explanation  available  besides  her  recent  exposure  to  the  J&J 
COVID-19  vaccination  as  the  inciting  event  in  the  cascade  of 
events that led up to her hospitalisation.

OUTCOME AND FOLLOW-UP
Unfortunately, 1 day after discharge, the patient presented with 
numbness and tingling of her face and right arm and was eval-
uated  for  a  possible  stroke  with  MRI  brain  without  contrast, 
CT angiogram of the head and CT head without contrast. MRI 
and  CT  of  the  head  without  contrast  were  negative  for  any 
intracranial processes, but CT angiogram of the head and neck 
was  positive  for  a  non- occlusive  right  internal  carotid  artery 
(ICA) thrombus in the right carotid bulb/proximal right ICA. It 
measured 1.5 cm in the craniocaudal dimension (figure 3). The 
patient  was  diagnosed  with  a  transient  ischaemic  attack  (TIA) 
and  admitted  for  further  management.  She  is  presently  still 
living and was discharged home on fondaparinux 7.5 mg subcu-
taneously, once a day, for 1 month and is to be transitioned to 
apixaban 5 mg orally, two times per day, for 5 months, totalling 
6 months of anticoagulant therapy. She will be followed up as an 
outpatient by her haematologist and primary care physician for 
further management.

DISCUSSION
The continued efforts to control the COVID-19 pandemic have 
led to the approval of multiple vaccines across the globe including 

2

Malik B, et al. BMJ Case Rep 2021;14:e243975. doi:10.1136/bcr-2021-243975

B
M
J
 
C
a
s
e
R
e
p

 

:
 
f
i
r
s
t
 

p
u
b

l
i

s
h
e
d
a
s
 

 

.

1
0
1
1
3
6

/

b
c
r
-
2
0
2
1
-
2
4
3
9
7
5
 
o
n
 
1
4
 
J
u
y
 
2
0
2
1
.
 

l

l

D
o
w
n
o
a
d
e
d
 
f
r
o
m
 
h
t
t
p
:
/
/
c
a
s
e
r
e
p
o
r
t
s
.
b
m

j
.
c
o
m

/
 
o
n
 
O
c
t
o
b
e
r
 
4
,
 
2
0
2
2
 
b
y
 
g
u
e
s
t
.
 

t

 

P
r
o
e
c
t
e
d
b
y
 
c
o
p
y
r
i
g
h
t
.

Table 1  Summary table outlining the workup performed to rule out 
underlying thrombotic disorders

Test

One- time tests

On admission

On discharge

On readmission

Negative

168

132

Decreased 
platelet 
sufficiency

5.77

6.14

Thrombocytopenia 
with high mean 
platelet volume (MPV)

233

COVID-19 (Rapid Abbott)

Prothrombin Time (PT) (s)

Activated Partial 
Thromboplastin Time (aPTT) (s)

International Normalized 
Ratio (INR)

Fibrinogen (mg/dL)

Platelets (×103/μL)

Slide review

D- dimer (mg/L)

White Blood Cell Count (WBC) 
(×103/μL)

Rheumatoid factor (IU/mL)

Anti- DS DNA

Anti- Smith antibody

Negative

Negative

Cardiolipin IgA/G/M (U/mL)

0.7/<1.6/1.8

Factor V Leiden mutation

Negative

Peripheral smear

Lactate Dehydrogenase 
(LDH) (U/L)

Indirect Coombs

Blood type ABO/Rh

Prothrombin factor II 
20210G>A mutation

anti- nuclear antibody (ANA)

Positive

Antithrombin III activity

143 %

Antithrombin III antigen

Negative

O positive

Negative

113%

113%

117%

88%

113%

Protein C activity

Protein C antigen

Protein S activity

Protein S antigen

Hexagonal phospholipids

Negative

Heparin induced platelet Ab 
(HIT) (PF4 Ab) (Units- OD)

2.702

Platelet Ab direct flow 
cytometry

Negative

Factor VIII antigen

180%

Lupus inhibitor/anticoagulant

Creatinine (mg/dL)

Troponin I (ng/mL)

PF4, platelet factor 4.

–

–

–

–

–

–

–

–

–

9

–

–

–

Negative

12.2

26.4

1.13

142

21

Decreased 
platelet 
sufficiency

>35.20

7.14

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

–

Negative, test 
suggestive of heparin 
effect

0.8

0.003

0.8

0.87

0.1070

the  Pfizer  (BNT162b2mRNA),  Moderna  (mRNA-1273),  J&J 
(Ad26.COV2.S) and AstraZeneca (AZD1222) vaccines. Multiple 
countries  have  reported  a  series  of  rare  thromboembolic  inci-
dents, most commonly CSVT or DVT of the lower limbs, asso-
ciated  with  thrombocytopenia  and  occurring  7–14  days  after 
vaccination  with  certain  COVID-19  vaccines.10  These  adverse 
events  have  led  many  countries,  including  Germany  and  the 
USA, to temporarily pause the administration of the vaccines in 
question to further investigate these cases.

CVST is a rare condition that affects 0.22–1.57 per 100 000 
population annually and accounts for approximately 0.5%–1% 
of all strokes per year.9 The median age of patients presenting 
with CVST is 37 years old and approximately 8% of patients are 
65 years of age or older at the time of diagnosis. Multiple iden-
tifiable  risk  factors  have  been  identified,  including  prothrom-
botic conditions (inherited or acquired), use of hormone therapy 
(including  oral  contraceptive  pills),  pregnancy  and  the  post-
partum  period,  malignancy,  infection  and  mechanical  precipi-
tants (lumbar punctures). As of 12 April 2021, there have been 

Case report

B
M
J
 
C
a
s
e
R
e
p

 

:
 
f
i
r
s
t
 

p
u
b

l
i

s
h
e
d

 

a
s
 

1
0

.

1
1
3
6

/

b
c
r
-
2
0
2
1
-
2
4
3
9
7
5
 
o
n
 
1
4
 
J
u
y
 
2
0
2
1
.
 

l

l

D
o
w
n
o
a
d
e
d
 
f
r
o
m
 
h
t
t
p
:
/
/
c
a
s
e
r
e
p
o
r
t
s
.
b
m

j
.
c
o
m

/
 
o
n
 
O
c
t
o
b
e
r
 
4
,
 
2
0
2
2
 
b
y
 
g
u
e
s
t
.
 

t

 

P
r
o
e
c
t
e
d
b
y
 
c
o
p
y
r
i
g
h
t
.

Figure 3  CT angiogram demonstrating partially occlusive thrombus in 
the right internal carotid artery (yellow arrow).

six  reported  cases  of  CVST  associated  with  thrombocytopenia 
(platelet  counts  <150 000/mm3)  within  the  USA  after  the 
administration  of  approximately  6.86 million  doses  of  the  J&J 
COVID-19 vaccination.9

The pathophysiological mechanism underlying these events has 
been termed vaccine- induced immune thrombotic thrombocyto-
penia (VITT) (now termed ‘thrombosis with thrombocytopenia 
syndrome (TTS)’ by the US FDA and CDC in a recent update).11 
It mimics heparin- induced thrombocytopenia (HIT) with a posi-
tive  platelet- activating  antibody  to  platelet- factor  4  (PF4  Ab)/
heparin  complexes,  thrombocytopenia  and  a  predisposition  to 
forming thrombi. The mechanism is thought to be emulated by 
polyanionic constituents of the AZD1222 (AstraZeneca) vacci-
nation.10  The  exact  mechanism  behind  these  adverse  events 
in  the  J&J  vaccination  is  thought  to  be  similar  to  the  process 
described for the AZD1222 vaccination.12 The American Society 
of Hematology presented VITT/ TTS as a medical entity in April 
2021.  The  diagnostic  criteria  included  (1)  COVID-19  vaccina-
tion  (AstraZeneca  or  J&J)  within  4–30 days  prior,  (2)  throm-
bosis (often cerebral or abdominal), (3) thrombocytopenia, (4) 
positive  PF4  HIT  ELISA.11  All  four  criteria  need  to  be  met  to 
qualify for the diagnosis, as in our patient. An additional finding 
unique to our patient in comparison to the six cases published 
in the article by See et al13 was the development of TIA (arte-
rial thrombus) 1 day after discharge, despite being on apixaban. 
Arterial thrombus formation itself is a rare phenomenon and our 
patient did not have any predisposing factors present at the time 
of assessment. Likely, her TIA and associated arterial thrombus 
were also associated with her hypercoagulable state, attributed 
herein to the uptake of the vaccination just 10 days prior.

No  definitive  treatment  has  been  established  thus  far  but 
the research conducted by von Hundelshausen et al suggested 
plasma exchange with plasma rather than albumin is an effective 
way of reducing the pathologic antibody load in the serum and 
providing correction of the hypofibrinogenaemia.10 In the same 
research, von Hundelshausen et al proposed an alternative treat-
ment for TTS by using Bruton tyrosine kinase (Btk) inhibitors. 
Btk  inhibitors  are  currently  approved  for  B- cell  malignancies 

3

Malik B, et al. BMJ Case Rep 2021;14:e243975. doi:10.1136/bcr-2021-243975

Case report

and  act  to  pleiotropically  target  multiple  pathways  down-
stream of the gamma Fc receptor IIa (FcγRIIA). They have been 
demonstrated  to  effectively  inhibit  platelet  aggregation,  dense 
granule secretion, P- selectin expression and platelet- neutrophil 
aggregate  formation  stimulated  by  FcγRIIA  cross- linking.10 
Moreover, platelet C- type lectin- like receptor-2 (CLEC-2) and 
glycoprotein  Ib- mediated  platelet  activation,  interaction  and 
activation of monocytes and the release of neutrophil extracel-
lular traps (as encountered in HIT) are also attenuated by Btk 
inhibitors.10

Despite the significant thrombocytopenia that can be encoun-
tered with these patients, the avoidance of platelet transfusions is 
critical. Additional platelets would provide a substrate for further 
antibody- mediated platelet activation and coagulopathy.10 Since 
TTS mimics HIT (ie, it is PF4 Ab positive) and it is a hypercoag-
ulable  state,  anticoagulation  with  a  non- heparin  anticoagulant, 
such  as  argatroban,  danaparoid,  fondaparinux  or  direct  oral 
anticoagulants,  is  recommended.4  Further  workup  to  evaluate 
for  alternative  aetiologies  of  hypercoagulability  or  underlying 
procoagulant disorders, including thrombotic- thrombocytopenic 
purpura, atypical haemolytic uremic syndrome and antiphospho-
lipid syndrome, should be performed before diagnosing TTS.14 
An alternative diagnosis could significantly impact management 
decisions.  Physicians  should  have  a  low  threshold  for  further 
evaluation in patients who recently received the J&J COVID-19 
vaccine (ie, within 4–30 days) and present with signs/symptoms 
of  thrombosis  (DVT,  CVST,  intra- abdominal).  Anticoagulation 
should be considered as detailed above.

Patient’s perspective

I felt like I had a stroke and that I might die. I did not feel 
safe at home because I thought to myself that anything could 
happen at any time. I was frustrated that in taking a step to 
safeguard myself against COVID-19, I experienced so many other 
complications. I am thankful to be alive, but even if I had to take 
the vaccine again I would do it in view of the risk that COVID-19 
poses.

Learning points

 ► Consider thrombosis with thrombocytopenia syndrome (TTS) 
as part of the differential diagnosis in a patient presenting 
with thrombosis (cerebral venous sinus thrombosis, deep vein 
thrombosis, pulmonary embolism) within 30 days of receiving 
AstraZeneca or Johnson & Johnson COVID-19 vaccines.
 ► Use the four criteria as outlined by the American Society of 

Hematology to diagnose TTS.

 ► In the appropriate clinical situation where the clinician’s 
suspicion for TTS is high and there are no absolute 
contraindications, use non- heparin anticoagulants to 
anticoagulate the patient.

 ► Provide patients with information regarding the possibility of 
experiencing thrombotic events during the process of shared 
decision- making regarding vaccination.

Contributors  BM, A Kalantary and KR contributed equally in the researching, 
writing and editing of the manuscript. A Kunadi supervised the project and made 
significant changes to the final manuscript. All authors were in agreement with 
the finalised manuscript to be submitted for publication. All authors agreed to be 
accountable for all aspects of the work in ensuring that questions related to the 
accuracy or integrity of any part of the manuscript are appropriately investigated and 
resolved.

Funding  The authors have not declared a specific grant for this research from any 
funding agency in the public, commercial or not- for- profit sectors.

Competing interests  None declared.

Patient consent for publication  Obtained.

Provenance and peer review  Not commissioned; externally peer reviewed.

This article is made freely available for use in accordance with BMJ’s website 
terms and conditions for the duration of the covid-19 pandemic or until otherwise 
determined by BMJ. You may use, download and print the article for any lawful, 
non- commercial purpose (including text and data mining) provided that all copyright 
notices and trade marks are retained.

ORCID iD
Bilal Malik http:// orcid. org/ 0000- 0001- 8762- 7321

REFERENCES
  1   Acpinternist. org. Clot concerns with adenovirus COVID-19 vaccines, antibody 

treatment recommendations and data [Internet], 2021. Available: https:// acpinternist. 
org/ weekly/ archives/ 2021/ 04/ 20/ 1. htm? utm_ campaign= FY20- 21_ NEWS_ 
INTERNIST_ DOMESTIC_ 042021_ EML& utm_ medium= email& utm_ source= Eloqua
  2  Shimabukuro T. ACIP April 14, 2021 Presentation Slides | Immunization Practices | 

CDC [Internet], 2021. Available: https://www. cdc. gov/ vaccines/ acip/ meetings/ slides- 
2021- 04. html

  3  Schuchat A, Marks P. Joint CDC and FDA Statement on Johnson & Johnson COVID-19 
Vaccine [Internet], 2021. Centers for disease control and prevention. Available: 
https://www. cdc. gov/ media/ releases/ 2021/ s0413- JJ- vaccine. html

  4  Scully M, Singh D, Lown R, et al. Pathologic antibodies to platelet factor 4 after 

ChAdOx1 nCoV-19 vaccination. N Engl J Med 2021;384:2202–11.

  5  European Medicines Agency. COVID-19 Vaccine Janssen: EMA finds possible link to 

very rare cases of unusual blood clots with low platelets - European Medicines Agency 
[Internet], 2021. Available: https://www. ema. europa. eu/ en/ news/ covid- 19- vaccine- 
janssen- ema- finds- possible- link- very- rare- cases- unusual- blood- clots- low- blood
  6  Johnson & Johnson. Johnson & Johnson COVID-19 Vaccine Roll- out to Resume in 

Europe Following European Medicines Agency (EMA) Review, EMA Confirms Overall 
Benefit- Risk Profile Remains Positive [Internet], 2021. Available: https://www. jnj. com/ 
johnson- johnson- covid- 19- vaccine- roll- out- to- resume- in- europe- following- european- 
medicines- agency- ema- reviewema- confirms- overall- benefit- risk- profile- remains- 
positive

  7  Centers for Disease Control and Prevention. CDC Recommends Use of Johnson & 
Johnson’s Janssen COVID-19 Vaccine Resume [Internet], 2021. Available: https://
www. cdc. gov/ coronavirus/ 2019- ncov/ vaccines/ safety/ JJUpdate. html

  8  Muir K- L, Kallam A, Koepsell SA, et al. Thrombotic thrombocytopenia after Ad26.
COV2.S vaccination. New England Journal of Medicine 2021;384:1964–5.
  9  Sadoff J, Davis K, Douoguih M. Thrombotic Thrombocytopenia after Ad26.COV2.S 
Vaccination - Response from the Manufacturer. N Engl J Med 2021;384:1965–6.
 10  von Hundelshausen P, Lorenz R, Siess W, et al. Vaccine- Induced immune thrombotic 
thrombocytopenia (VITT): targeting pathomechanisms with Bruton tyrosine kinase 
inhibitors. Thromb Haemost 2021. doi:10.1055/a-1481-3039. [Epub ahead of print: 
13 Apr 2021].

 11  et alBussel J, Connors J, Cines D. Thrombosis with Thrombocytopenia Syndrome 

[Internet].  Hematology. org, 2021. Available: https://www. hematology. org/ covid- 19/ 
vaccine- induced- immune- thrombotic- thrombocytopenia

 12  Greinacher A, Thiele T, Warkentin TE, et al. Thrombotic thrombocytopenia after 

ChAdOx1 nCov-19 vaccination. N Engl J Med 2021;384:2092–101.

 13  See I, Su JR, Lale A, et al. US case reports of cerebral venous sinus thrombosis with 

thrombocytopenia after Ad26.COV2.S vaccination, March 2 to April 21, 2021. JAMA 
2021;325:2448.

 14  Oldenburg J, Klamroth R, Langer F. Diagnosis and management of vaccine- related 

thrombosis following AstraZeneca COVID-19 vaccination: guidance statement from 
the GTH. Hamostaseologie 2021. doi:10.1055/a-1469-7481

4

Malik B, et al. BMJ Case Rep 2021;14:e243975. doi:10.1136/bcr-2021-243975

B
M
J
 
C
a
s
e
R
e
p

 

:
 
f
i
r
s
t
 

p
u
b

l
i

s
h
e
d
a
s
 

 

.

1
0
1
1
3
6

/

b
c
r
-
2
0
2
1
-
2
4
3
9
7
5
 
o
n
 
1
4
 
J
u
y
 
2
0
2
1
.
 

l

l

D
o
w
n
o
a
d
e
d
 
f
r
o
m
 
h
t
t
p
:
/
/
c
a
s
e
r
e
p
o
r
t
s
.
b
m

j
.
c
o
m

/
 
o
n
 
O
c
t
o
b
e
r
 
4
,
 
2
0
2
2
 
b
y
 
g
u
e
s
t
.
 

 

t

P
r
o
e
c
t
e
d
b
y
 
c
o
p
y
r
i
g
h
t
.

Case report

Copyright 2021 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit
https://www.bmj.com/company/products-services/rights-and-licensing/permissions/
BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission.

Become a Fellow of BMJ Case Reports today and you can:
 ► Submit as many cases as you like
 ► Enjoy fast sympathetic peer review and rapid publication of accepted articles
 ► Access all the published articles
 ► Re-use any of the published material for personal use and teaching without further permission

Customer Service
If you have any further queries about your subscription, please contact our customer services team on +44 (0) 207111 1105 or via email at support@bmj.com.

Visit casereports.bmj.com for more articles like this and to become a Fellow

B
M
J
 
C
a
s
e
R
e
p

 

:
 
f
i
r
s
t
 

p
u
b

l
i

s
h
e
d
a
s
 

 

.

1
0
1
1
3
6

/

b
c
r
-
2
0
2
1
-
2
4
3
9
7
5
 
o
n
 
1
4
 
J
u
y
 
2
0
2
1
.
 

l

l

D
o
w
n
o
a
d
e
d
 
f
r
o
m
 
h
t
t
p
:
/
/
c
a
s
e
r
e
p
o
r
t
s
.
b
m

j
.
c
o
m

/
 
o
n
 
O
c
t
o
b
e
r
 
4
,
 
2
0
2
2
 
b
y
 
g
u
e
s
t
.
 

 

t

P
r
o
e
c
t
e
d
b
y
 
c
o
p
y
r
i
g
h
t
.

5

Malik B, et al. BMJ Case Rep 2021;14:e243975. doi:10.1136/bcr-2021-243975