Acute hepatitis following mRNA BNT162b2 COVID-19 vaccination.

BACKGROUND: Widespread administration of COVID-19 vaccinations have led to reports of rare but potentially serious side effects. METHODS: We present two cases of acute hepatitis following mRNA BNT162b2 (Comirnaty, Pfizer-BioNTech) vaccination. RESULTS: A 25-year-old male presented to hospital with progressive jaundice 5 days following his second dose of Comirnaty. Initial bloodwork revealed severe hepatocellular enzyme elevation and conjugated hyperbilirubinemia with preserved INR. Extensive serologic workup was negative, with normal imaging. Percutaneous liver biopsy was performed and revealed acute cholestatic hepatitis possibly related to drug-induced liver injury. He was started on prednisone 40 mg daily with good initial response but had a second flare; a biopsy was repeated which showed near-identical findings. Steroids were discontinued given non-response and the patient had gradual near complete resolution of liver enzymes and hyperbilirubinemia. A 32-year-old male presented with a 4-week history of nausea followed by progressive choluria, jaundice, and pruritis. He received his second dose of Comirnaty vaccination two weeks prior to presentation. Initial bloodwork showed mixed enzyme elevation with hyperbilirubinemia. Serological workup and imaging were unrevealing. He underwent liver biopsy which showed severe intrahepatic cholestasis, with drug-induced liver injury being suggested as most likely cause. His course was self-limited with resolution of serological abnormalities and symptoms. CONCLUSIONS: While overwhelmingly safe on a population level, our case series illustrate two cases of acute icteric hepatitis following mRNA BNT162b2 vaccination. Clinicians should be aware of this association with hepatic inflammation and consider vaccine history an important component of evaluating patients with acute liver injury.

Management of cancer-associated upper extremity deep vein thrombosis with and without venous catheters at a tertiary care center.

INTRODUCTION: Data on management of upper extremity deep vein thrombosis (UEDVT) in patients with cancer is limited. The objective of this study was to determine risk factors for UEDVT and the rates of recurrence and bleeding in a real-world setting. METHODS: Retrospective review of consecutive patients assessed for cancer-associated UEDVT. Outcome measures were recurrent venous thromboembolism (VTE), and major and clinically relevant non-major bleeding (CRNMB). Risk factors for recurrent VTE and bleeding were assessed. RESULTS: Mean duration of follow-up was 7.2 months. Two hundred cases were identified; 69% were associated with a central line. Non-line associated UEDVT occurred more frequently in the setting of breast cancer, lung cancer and documented local mass effect. The incidence of recurrent VTE was 18.5%, of which 14 (37.8%) were ipsilateral UEDVT. The risk of recurrence is higher with male gender (HR 2.0, 95% CI; 1.0-4.0). Major and CRNMB occurred in 1% and 11.5%, respectively. Concurrent use of an antiplatelet agent was associated with a higher risk of CRNMB compared to anticoagulant therapy alone (HR 3.9, 95% CI; 1.4-10.7). CONCLUSIONS: Presence of a venous catheter was the primary risk factor for UEDVT, however, extrinsic compression by local tumour may be just as important for some cancer types. Furthermore, the majority of recurrent events did not occur in the same upper limb suggesting that UEDVT may be predictive of increased thrombotic risk rather than just a local effect of catheters.

Outcomes of low-molecular-weight heparin treatment for venous thromboembolism in patients with primary and metastatic brain tumours.

Venous thromboembolism (VTE) is one of the most common complications in patients with brain tumours. There is limited data available in the literature on VTE treatment in these patients. We conducted a matched retrospective cohort study of patients with primary or metastatic brain cancer who were diagnosed with cancer-associated VTE. Patients were selected after a retrospective chart review of consecutive patients who were diagnosed with cancer-associated VTE between January 2010 and January 2014 at the Juravinski Thrombosis Clinic, Hamilton, Canada. Controls were age- and gender-matched patients with cancer-associated VTE from the same cohort, but without known brain tumours. A total of 364 patients with cancer-associated VTE were included (182 with primary or metastatic brain tumours and 182 controls). The median follow-up duration was 6.7 (interquartile range 2.5-15.8) months. The incidence rate of recurrent VTE was 11.0 per 100 patient-years (95 % CI; 6.7-17.9) in patients with brain tumours and 13.5 per 100 patient-years (95 % CI; 9.3-19.7) in non-brain tumour group. The incidence of major bleeding was 8.6 per 100 (95 % CI; 4.8-14.7) patient-years in patients with brain tumours versus 5.0 per 100 patient-years (95 % CI; 2.8-9.2) in controls. Rate of intracranial bleeding was higher in brain tumour patients (4.4 % vs 0 %, p-value=0.004). In summary, rates of recurrent VTE and major bleeding were not significantly different in patients with cancer-associated VTE in the setting of primary or metastatic brain tumours compared those without known brain tumours. However, greater numbers of intracranial bleeds were observed in patients with brain tumours.