LAUSR

A healthy 45-year-old woman received the first dose of AstraZeneca ChAdOx1 vaccination against SARSCoV-2. Eight days later, she presented to the emergency department with new onset of severe bilateral flank pain where she was assessed and diagnosed with a herniated disk. She was discharged without any abdominal imaging performed. At home, she rapidly deteriorated and was brought back by her family 2 days later with severe generalized weakness and decreased level of consciousness. Bloodwork showed thrombocytopenia with platelet count 82 · 109/L. Noncontrast CT head was interpreted as normal. CT of the chest, abdomen, and pelvis although showed multiple subsegmental pulmonary emboli, left renal vein embolism, left common iliac, and renal vein thrombi (Fig. 1A, B). Bilateral hemorrhagic adrenal infarction was present, accounting for her flank pain (Fig. 1C). Heparininduced thrombocytopenia (HIT) assay was performed and was positive confirming the diagnosis of vaccine-induced thrombotic thrombocytopenia (VITT). She was admitted to the intensive care unit and treatment with intravenous argatroban commenced at 3.6 mL/hour for 2 days, and she was then transitioned to oral rivaroxaban 15 mg twice daily. She also received intravenous immunoglobulins (IVIg) 1 g/ kg for 2 days. Her severe adrenal insufficiency was treated with IV hydrocortisone 25 mg 4 times daily. Four days later, she developed severe headaches, vertigo, and bilateral blurred vision. MRI of the brain with venography revealed extensive cerebral venous sinus thrombosis (CVST) involving the superior sagittal sinus, straight sinus, torcula, bilateral transverse sinuses, vein of Galen, and right internal jugular vein (Fig. 2A–C). Nonocclusive thrombus was present near the left carotid bifurcation (Fig. 2D), and there was right vertebral artery occlusion with an area of acute infarction in the right posterior inferior cerebellar artery territory (Fig. 2E–H). On ophthalmologic examination, the visual acuity was 20/20 and 20/25 and there was no relative afferent pupillary defect. Extraocular motility was full, and she was orthophoric on alignment testing. Ophthalmoscopy revealed severe bilateral optic nerve head edema with peripapillary hemorrhages. A total FIG. 1. Vaccine-induced thrombotic thrombocytopenia causing extensive venous thromboembolic events. A. Left internal iliac vein thrombosis (white arrow) on coronal CT with sagittal slices showing left lower pole renal infarction (B, black arrow) and C, coronal section revealing bilateral adrenal gland hemorrhagic infarction (white arrowheads).