Respiratory syncytial virus-mediated platelet factor 4 antibody positive immune thrombocytopenia in cerebral sinus vein thrombosis

Abstract-Text (inkl. Referenzen und Bildunterschriften)

A previously healthy, 20-year-old female kindergarten worker presented with headache, cough for 6 days, and acute onset left-sided homonymous hemianopia. Magnetic resonance imaging (MRI) including time of flight (TOF) venography showed an intracerebral hematoma (ICH) within the right parietal lobe. Laboratory examination revealed thrombocytopenia (43.000/L) and disseminated intravascular coagulopathy (DIC). A nasopharyngeal PCR testing for respiratory syncytial virus (RSV) was positive. Digital subtraction angiography (DSA) confirmed MRI suspected right-parietal small cortical vein thrombosis and partial occlusion of the right-sided sinus sigmoideus and internal jugular vein. Full-body CT-scan revealed peripheral pulmonary emboli and thrombosis of the commune left femoral, both internal iliac and portal veins. Therapeutic anticoagulation with continuous intravenous heparin was started. Subsequently, thrombocyte count normalized at day 5. MRI follow-up scan on day 7 showed progression of the thrombus to the right transverse sinus. The patient remained clinically stable. Testing for coagulopathies including JAK2-mutations and vasculitis was unremarkable, however, anti-platelet-factor-4 (PF4) antibodies including positive PF4-dependent platelet activation were detected. At day 14, hemianopia resolved completely. MRI on day 18 showed recanalization of the right sigmoid and transverse sinus and jugular vein. At discharge from hospital (day 21) the patient was switched to oral anticoagulation. At six months follow-up, anti-PF4-antibodies were not detected. The patient was asymptomatic, MRI showed complete recanalization of the cerebral sinus and anticoagulation was discontinued. In conclusion, this case adds to the accumulating evidence that respiratory viral infections should indeed be regarded as a pathogenetic contributor to coagulopathy associated with antibodies against PF4.