Lagos State University Teaching Hospital, Ikeja, Lagos Lagos State University college of Medicine, Ikeja, Lagos.

BACKGROUND: Mass immunization of the general population was one of the reactions to relieve the Extreme Intense Respiratory Disorder Covid 2 (SARs CoV-2) pandemic. A few minor and major unfavorable impacts have been accounted for.

METHODS: This study audited the clinico-pathologic boundaries of 4 patients with clinical what's more, biochemical coagulation irregularities following the organization of the Oxford AstraZeneca Coronavirus (ChAdOx1 nCoV-19) immunization. Their clinical, lab and radiological boundaries were recovered and recorded.

RESULTS: Every one of the patients had anomaly of coagulation with blood clot arrangement. Two of the revealed patients had a few gamble factors for apoplexy and in this way theirsicknesses might not have causal relationship with the inoculation while the other 2 patients had no great reason for their coagulation anomaly. Mortality was kept in two of the patients.

CONCLUSION: Extreme unfriendly impact of ChAdOx1 nCoV-19 Inoculation may not be interesting. Doctors ought to have a high file of doubt and there is likewise a need to upscale unfavorable occasions checking.

As of now, more than 200 and sixty million positive instances of Extreme Intense Respiratory Disorder Covid 2 (SARs CoV-2) have been accounted for with more than 5,000,000 Covid sickness 19 (COVID19) related passings worldwide. [1] As a component of the reaction to this pandemic,Nigeria, through the Public Essential Medical services Improvement Organization (NPHCDA), began the organization of the Oxford AstraZeneca Coronavirus (ChAdOx1 nCoV-19) immunization in Walk 2021. The underlying round of immunizations endured around a month. Need for the main period of the immunization was designated at bleeding edge laborers as well as other weak gatherings. As of April nineteenth, 2021, 317,916 portions of immunizations have been managed as first portion addressing around 1% of the 24 million populace in the megacity of Lagos. [1] Of this number, 14 instances of extreme and 419 instances of gentle unfriendly impacts related with the inoculation were accounted for.

Globally, there have been reports of antagonistic occasions following inoculation with the Oxford/Astra Zeneca as well as Johnson and Johnson immunizations. We report four instances of extreme antagonistic occasions of coagulation deserts among the people who got AstraZeneca COVID19 immunization in Lagos, Nigeria. The significance of this report is to confirm the clinico obsessive elements of these cases and decide whether there is a causative relationship with the immunization. Supposedly, this is the primary documentation of coagulation related serious symptoms of Oxford AstraZeneca Coronavirus (ChAdOx1 nCoV-19) in Nigeria.

This case series features four patients who were hospitalised to our hospitals after experiencing what was thought to be a serious adverse reaction to the covid-19 vaccination (abnormal coagulation with thrombus development). We examined their clinical manifestations, methods of therapy, and various outcomes, including the autopsy report. Tables were used to present the findings of the investigation and the patient characteristics. The patients' or their next-of-kin's-consent kin's was secured before the publication.

Patient 1 was a known diabetic and hypertensive woman in her 80s who had poor medication compliance. On March 25, 2021, she arrived at the medical emergency with a 3-hour history of right-sided limb weakness. Speech difficulty, facial asymmetries, and sensorium changes were also seen. She had never before experienced a cerebrovascular event (CVA). At rest, this occurrence took place. She had gotten the AstraZeneca COVID-19 vaccine two days before her presentation, and she was reported to have experienced a moderate headache afterward. Image confirmation follows an evaluation of Left Hemisphere Ischaemic CVA with Right Hemiparesis.

A Cerebrum X-ray completed 3 days after confirmation uncovered an intense ischaemic infarct with haemorrhagic change. Ten after 10 days, patient was seen to have reciprocal pedal expanding (Right>Left) stretching out to the lower 1/3 of the right leg with related differential warmth and delicacy. A recurrent D-Dimer done on that very day showed an increment from an earlier 5679.73ng/dL to 9735.95ng/dL. She was along these lines begun on subcutaneous enoxaparin 40mg day to day. Besides, venous Doppler sweep of both lower appendages done on day 15 of affirmation showed respective lower appendage profound venous apoplexy (DVT) with right subcutaneous enlarging. In this manner, she created unexpected beginning trouble in breathing same day and passed on in spite of endeavor at revival. The post after death discoveries showed elements of hypertensive coronary illness, tricuspid valve dilatation, profound vein apoplexy, summed up petechiae as well as persistent inactive blockage of the liver. Tests were taken from all organs for histology.

Ischaemic CVA, convoluted by two-sided Profound Venous Apoplexy and Pneumonic Embolism.Patient 2 was a 34-year-elderly person who was alluded to a confidential hematology community on account of a 3-day history of hematuria, seeping into the skin and gums. He had been generally well preceding beginning of these side effects. The main critical openness in the previous month was AstraZeneca Coronavirus immunization which he had gotten 7 days before beginning of side effects. Huge assessment discoveries uncovered petechial rashes on arms and draining gums. His circulatory strain was 143/92mmHg. Examination results at show showed a hematocrit of 41%, white platelet count of 6.41x109/L, Platelet count of 2 x109/L. Erythrocyte sedimentation rate (ESR) of 35mm/hr., D-dimer of 0.32 ( 0-0.5mcg/ml), draining season of 1min 30sec (1-4mins), Thickening season of 5min 47 sec (4-8min), Global standardized proportion of 0.98(0.9-1.2), Alanine transaminase level of 64.5U/L (0-45), Aspatate transaminaselevel of 75.5IU/L (0-40), Basic phosphatase level of 82IU/L (40-129) and gamma glutamyl transaminase level of 107.6IU/L (8-78). Complete Bilirubin and renal capability were ordinary. Pee microscopy culture and awareness showed egg whites ++, RBC+++, leucocytes + and no red cell projects. A recurrent full blood count completed 2 days after the fact showed a lower platelet count of 1 x 109/L.

Fringe blood film showed normochromic, normocytic red cells, sufficient on film, no schistocytes noticed, typical white platelet morphology, sufficient on film and no platelet bunches or platelets were seen on film.Patient was conceded and begun on IV Methylprednisolone 1g once day to day for 3 days, IV Omeprazole 80mg 12hourly, oral Amlodipine 10mg once everyday, oral Carvedilol 12.5mg two times everyday and intravenous levofloxacin 500mg once day to day. He was bonded with 3 restorative units of apheresis platelets (Portion 150 x 109/L) on same day. The hematuria halted around 2hours in the wake of getting the platelet bonding; but rehash platelet count around 12hrs post- bonding stayed 1 x 109/L. This affirmed the doubt of insusceptible intervened plateletutilization. Patient was initiated on intravenous immunoglobulins at 0.5g/Kg/day for 2days. Platelet count was 28 x 109/L and 80 x109/L on day 1 and 2 individually followingintravenous immunoglobin implantation. D-dimer stayed inside typical cutoff points however the liver capability remained somewhat disturbed while renal capability stayed ordinary. Venous doppler checks and abdominopelvic CT filters were all ordinary and rejected apoplexy.

stayed stable and was released for follow up and has stayed well. Platelet Element 4 antibodies and Compound connected Immunosorbent Examine (PF4 ELISA) were negative.Last Determination: Insusceptible Thrombocytopenic Purpura. Patient 3 was a 36-year-old female who introduced at a confidential office by virtue of left lower appendage enlarging of about fourteen days span. The enlarging was said to have been slow in beginning. It started as a puffy lower leg which continuously expanded in size, was at first non-delicate yet later related with torment following seven days. The enlarging was restricted to the left calf and average thigh.She had urinary side effects and no set of experiences reminiscent of cardiovascular breakdown. She was ambulant and well before the beginning of this sickness yet she anyway got Coronavirus immunization at an Essential Medical care Place six days before the beginning of disease. She accordingly created rash,expanding and staining at the infusion site. Complete blood count done at showshowed Hemoglobin of 7.4 g/dL, MCV of 46.4 fl (76-96), MCH of 18pg (27-32), MCHC of 27.2g/dL(31-36), all out white cell count of 5,800/L, Neutrophil 63.6%, Lymphocytes 27.4%,Eosinophil 2.9%, Basophil 0.3% and platelets of 311,000 mm3. D-dimer was raised previously 3000ng/ml (rehash >10,000ng/ml) while her renal capability was inside ordinary cutoff points. She had a stomach CT check which showed huge uterine fibroid in vicinity and compacting the left normal iliac vessel and the doppler ultrasound of the left leg showed clusters in the left iliac vein stretching out to the popliteal vein. A conclusion of obstructive profound venous apoplexy with basic lack of iron pallor auxiliary to menorrhagia from uterine fibroid was made.

Patient was treated with anticoagulation and iron trade treatment and alluded for additional the executives of uterine problem and the lack of iron sickliness. Last Analysis: Profound Venous Apoplexy optional to iliac vein pressure. Patient 4 was a 48-year-elderly person, conceded by means of the health related crisis on reference from a auxiliary medical services office in Lagos. He gave simple fatigability and weight reduction of one-month term, hack and shortness of breath of about fourteen days length. There was related history of high-grade fever, dousing night sweats and gum dying. He was likewise noted to have summed up pounding migraine and had passed 5 episodes of non-ridiculous loose bowels. There was no set of experiences of visual obscuring, no draining from some other openings. No set of experiences of repetitive chest torment, no haemoptysis and no decrease in pee yield. Side effects was said to have begun three days subsequent to taking Coronavirus Antibody. His social history is critical for utilization of 14units of liquor each week for over 10 years and he had 13.5 pack years of cigarette. No critical past clinical history. Before show at LASUTH, he had 7 pints of blood bonded at the alluding clinic because of low stuffed cell volume (PCV). The full blood count (CBC) from the alluding emergency clinic showed a PCV of 12%, WBC of 80.8 X 109/L,platelet count of 22,000 mm3 with myeloid impact cells reminiscent of intense myeloid leukemia M4.On broad assessment, he was constantly sick looking and dyspnoeic.

Respiratory framework assessment uncovered coarse crepitations on the right side with an oxygen immersion of 85% in room air. Examinations done at show incorporated a Chest X-beam which showed inconsistent opacities in the right hemi chest. A recurrent FBC (post bonding) showed PCV of 20.2%, WBC of 88.6X109/L and extreme thrombocytopenia with a platelet count of 900mm3. An appraisal of thought intense myeloid leukemia muddled by sepsis was made and his administration included parenteral anti-toxins, intravenous liquids, new entire blood bonding, oxygen treatment and other steady medicines. He was assessed by hematologists however his condition weakened and he kicked the bucket on the next day after show at our office.

Both the Johnson & Johnson vaccine as well as the Oxford/Astra Zeneca vaccine have been linked to adverse occurrences on a global scale. Any unfavourable medical incident that occurs after immunisation is referred to as an adverse event following immunisation (AEFI). Such occurrences could take place in healthy people and not necessarily be related to vaccination use. [2] Thrombo-embolic events were the most serious AEFIs after COVID-19 vaccination that were recorded. [3,4] As a result, the distribution of several vaccines has been halted or their use has been limited to a specified age range. [5] Despite a lengthier vaccine roll-out process and thus lower vaccine coverage in Africa compared to high income nations, there is hardly any literature on such instances.

We describe four cases of people who, after receiving the Oxford/AstraZeneca COVID 19, ChAdOx1 nCoV-19 vaccine in Lagos, Nigeria, presented with symptoms that were thought to be AEFI.Patient 1 did not imply that the vaccination was to blame for the thrombotic events that occurred. The patient had a number of risk factors for cerebrovascular disease before to vaccination, including her advanced age, chronic hypertension, and diabetes. Furthermore, a thorough post-mortem investigation revealed no conclusive correlation. When two patients experienced transverse myelitis after getting the COVID 19 vaccine in the latter half of 2020, discussion surrounding the connection between the vaccine and neurological complications began. [6] One of these was subsequently reported to be unrelated to the administration of the vaccine. [7] Additionally, the preliminary results of the mRNA vaccine experiment revealed that 7 of Bell's palsy was claimed to have occurred in 37,000 vaccination recipients, but it was later determined that this was not statistically different from Bell's palsy in the general population. [8] According to the current advice from authorised authorities, the advantages of the vaccine outweigh the dangers of neurologic problems by a large margin. [9] Patient 1 did not exhibit thrombocytopenia, which was a characteristic of previously described cases of post-vaccine thrombosis [4,10–12], but she did experience a slight decline in her platelet count six days after admission. In situations of post-vaccination thrombosis, an immunoglobulin G (IgG) assay against the PF-4 heparin complex was described, and it is now advised for patients who exhibit thrombotic or thrombocytopenic symptoms. [10,13] No patient was used for this test.

1 due to a lack of facilities. There was insufficient evidence to infer that the vaccine caused the ischemic stroke or venous thromboembolism that occurred, except from a temporal connection with the vaccine administration. The patient did not meet the demography, and there were other confounders that may have been more appropriately blamed for her symptoms. Limitations in patient 1 include the absence of a thorough assessment of prothrombotic status and a SARS-CoV-2 test. However, the lack of information about neurological signs following ChAdOx1 nCoV-19 vaccination in our environment made our suspicion and subsequent studies into this case important.

Symptoms of a disease known as vaccine-induced prothrombotic immune thrombocytopenia (VIPIT) or vaccine-induced immune thrombotic thrombocytopenia (VIITT) were found in Patient 2. (VITT). The term "thrombosis with embolism" now refers to the same syndrome.Systemic Thrombocytopenia (TTS). [14] This uncommon condition is identified by COVID 19 immunisation (four to thirty days prior, administered by Oxford/AstraZeneca or Johnson and Johnson thrombocytopenia, a PF4/polyanion complex antibody positive test, and venous or thrombosis of the arteries; frequently cerebral or abdominal. [4,14] The patient had the shot seven days ago. Thrombocytopenia was present, but the PF4 antibody was not tested because it was non-functional availability. These are important restrictions in this instance. But it's important to understand that The patient received IV immunoglobulin and prednisolone with success. The blood loss event was resolved the platelet count stayed at 1x 109/L immediately after the platelet transfusion. This supported the theory that it had an autoimmune genesis. Following therapy, this patient made a full recovery and was monitored in the outpatient clinic. In contrast, Schultz et al increased fatality rates in VITT patients who received platelet transfusions as part of their treatment modalities. [15] TTS is uncommon, however it's becoming more common when it comes to ChAdOx 1 nCoV-19 Immunization. [4]

Deep vein thrombosis struck Patient 3 six days after receiving the ChAdOx1 nCoV-19 vaccine. She also has a remarkably high D-dimer. A contrast-enhanced abdominal CT, however, revealed a significant fibroid squeezing the left common iliac vein. The fact that the patient was healthy and active prior to inoculation suggests that the vaccine may have a pro-thrombotic effect. [16] The final patient experienced a simmering illness and underwent thrombocytopenia 3 days after receiving the ChAdOx1 nCoV-19 vaccine. He was given seven units of whole blood from the referral centre, but he never underwent a platelet transfusion or received any type of conclusive steroid or immunoglobulin therapy because he passed away soon after arriving at our clinic. Although his initial clinical characteristics strongly imply leukaemia, his thrombocytopenia may have been brought on by a covid vaccine.

Following SARS nCoV-2 immunisation, new cases of acute immune thrombocytopenia purpura (ITP) have been recorded. [17,18] Most cases of thrombocytopenia are less severe than 10,000/L. In order to rule out TTS in this kind of situation, the American Society of Haematology advises starting treatment with IVIG and/or steroids while awaiting a negative anti PF4 result. [14] This emphasises the requirement for a strong index of suspicion and prompt therapy commencement following clinical suspicion.

A high index of suspicion should be the guiding principle in light of the occurrences in these 4 cases, which indicate that the discussion around the link between the ChAdOx1 nCoV-19 vaccine and clot formation in Europe should not be seen as unique to Africa. In particular in this region of the world, there is a need for intensive adverse event surveillance and additional research on these adverse occurrences is crucial.

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4. Greinacher A, Thiele T, Warkentin TE, Weisser K, Kyrle PA, Eichinger S. Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination. The New England journal of medicine. 2021.

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9. Goss AL, Samudralwar RD, Das RR, Nath A. ANA Investigates: Neurological Complications of COVID-19 Vaccines. Annals of neurology. 2021;89(5):856-7.

10. Wolf ME, Luz B, Niehaus L, Bhogal P, Bäzner H, Henkes H. Thrombocytopenia and Intracranial Venous Sinus Thrombosis after “COVID-19 Vaccine AstraZeneca” Exposure. Journal of Clinical Medicine. 2021;10(8):1599.

11. Schultz NH, Sørvoll IH, Michelsen AE, Munthe LA, Lund-Johansen F, Ahlen MT, et al. Thrombosis and thrombocytopenia after ChAdOx1 nCoV-19 vaccination. New England Journal of Medicine. 2021.

12. Muir K-L, Kallam A, Koepsell SA, Gundabolu K. Thrombotic Thrombocytopenia after Ad26. COV2. S Vaccination. New England Journal of Medicine. 2021.

13. Oldenburg J, Klamroth R, Langer F, Albisetti M, von Auer C, Ay C, et al. Diagnosis and Management of Vaccine- Related Thrombosis following AstraZeneca COVID-19 Vaccination: Guidance Statement from the GTH.Hamostaseologie. 2021.

14. Hematology ASo. Thrombosis with Thrombocytopenia Syndrome. https://wwwhematologyorg/covid-19/vaccine-induced-immune-thrombotic-thrombocytopenia. 2021.

15. Schultz NH, Sørvoll IH, Michelsen AE, Munthe LA, Lund-Johansen F, Ahlen MT, et al. Thrombosis and Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination. The New England journal of medicine. 2021.

16. Wise J. Covid-19: European countries suspend use of Oxford-AstraZeneca vaccine after reports of blood clots. BMJ (Clinical research ed). 2021;372:n699.

17. Helms JM, Ansteatt KT, Roberts JC, Kamatam S, Foong KS, Labayog JS, et al. Severe, Refractory Immune Thrombocytopenia Occurring After SARS-CoV-2 Vaccine. Journal of blood medicine. 2021;12:221-4.

18. Lee EJ, Cines DB, Gernsheimer T, Kessler C, Michel M, Tarantino MD, et al. Thrombocytopenia following Pfizer and Moderna SARS-CoV-2 vaccination. American journal of hematology. 2021;96(5):534-7.

Fabamwo A.O. A Clinico-Pathological Review of Coagulation Derangement in Four Cases Following the Chadox1 Ncov-19 Vaccination. Insights of Clinical and Medical Images 2022.