A 36-year-old female
- 2 weeks after getting the #CovidVaccine (AstraZeneca): fever, vomitting, severe headache, sudden onset of focal convulsions
- CT showed superior sagittal thrombosis
- She developed cardiac arrest & died 4 days
after admission
Case report
A 36-year-old female, known case of diabetes mellitus on oral therapy, presented to the emergency room with sudden onset of focal left-sided convulsions for 5 minutes followed by weakness in the left arm. She had a fever of 38.2 C° at home with vomiting and severe headache that started a few hours prior to presentation. Two weeks prior to the presentation, she received the first dose of the ChAdOx1 nCoV-19 vaccine. She had no history of any thromboembolic or connective tissue disorders. She was not on oral contraceptive pills or herbal remedies. On examination, the patient was conscious and oriented with tachycardia at 117 bpm. Her Glasgow coma scale (GCS) was 15/15, and cranial nerves examination was unremarkable. Motor examination showed left upper limb weakness at 3/5 on the Medical Research Council's scale with normal power of the right upper and bilateral lower limbs. Deep tendon reflexes were brisk on the left with Babinski sign. Sensory and coordination examinations were normal. Initial complete blood count upon admission showed elevated white blood cell count at 18.7×10"9/L (mainly neutrophils), low hemoglobin at 10.4 g/dL, and clumped platelets. Her liver enzymes (AST, ALT, lactate dehydrogenase, and GGT) were slightly elevated. Her coagulation profile showed prolonged PT (45 s), PTT (98 s), and INR (4.1) with D-dimer more than 35 mg/L. Blood smear showed leukocytosis of neutrophils with mild left shift, polychromasia, anisocytosis, Burr cells, and moderate thrombocytopenia with a few large platelets. A septic screen of blood, urine, and respiratory cultures was negative. COVID-19 PCR was negative. Brain computed tomography (CT) scan showed superior sagittal thrombosis with thickened cortical veins and bilateral hypodensites in the parietal lobes (Fig. 1). She was started on enoxaparin 80 mg, antibiotics, and antivirals. Two hours later, the patient became hypotensive and tachycardic with a drop in GCS from 15 to 8 necessitating transfer to the Intensive Care Unit (ICU) where she was intubated, mechanically ventilated, and started on ionotropic support. One day later, the patient deteriorated as she developed florid DIC with a drop in hemoglobin to 4 g/dL requiring massive blood transfusion. A repeat blood work showed a highly elevated white blood cell count at 48.4×10"9/L (mainly neutrophils), low platelets at 94×10"9/L, low fibrinogen at 0.6 g/L, and high creatinine at 254 umol/L. She developed acute kidney injury and severe acidosis requiring emergent hemodialysis. Enoxaparin was stopped due to DIC. A repeat brain CT scan showed multiple new bifrontal and biparietal hypodensites. The CT-venogram demonstrated extensive dural venous sinus thrombosis of the superior sagittal sinus and its cortical tributaries as well as the proximal left transverse sinus (Fig. 2). CT abdomen and pelvis showed extensive portal vein thrombosis with superior mesenteric vein thrombosis and potential splenic and hepatic infarction. The patient had a complicated course in the ICU given her multiple thromboses, DIC, difficulty to use anticoagulants, lactic acidosis, acute kidney injury, and multi-organ failure. She developed cardiac arrest with pulseless electrical activity and died four days after admission.
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