Disclosures: Benjamin T. Buterbaugh, DO: No financial relationships or conflicts of interest

Case Diagnosis: 83-year-old male with spontaneous intracerebral hemorrhage (ICH) due to acquired Factor IX and XI clotting disorder from COVID-19 vaccine

Case Description or Program Description: The patient was admitted with a spontaneous intracerebral hemorrhage managed conservatively before transfer to inpatient rehab facility. During his rehabilitation stay, he was found to have worsening left side weakness with concern for new spontaneous hemorrhage (ICH).

Setting: Academic Inpatient Rehabilitation Facility and Academic Acute Care Hospital

Assessment/Results: CT head showed expansion of the bleed in the right subinsular region and concern for new subfalcine and uncal herniation. Patient was transferred to the Neurosurgical ICU for further conservative management. Labs revealed an acute coagulopathy. Hematology was consulted and recommended mixing studies which did not correct, and Bethesda assay showing an acquired inhibitor of factor IX and XI. Malignancy workup and autoimmune titers were unremarkable. With unknown etiology, it was postulated that this may be vaccine related as patient received his last dose of the Moderna vaccine one month prior to admission and confirmed with positive COVID spike protein testing. Patient was placed on cyclophosphamide, rituximab, and high dose prednisone. He continued to have worsening weakness and dysphagia during his acute hospital admission and ultimately pursued comfort care.

Discussion (relevance): Acquired hemophilia is a rare bleeding disorder due to production of inhibitors and against the body’s own coagulation factors, which inhibits homeostasis. Deficiencies of factors IX and XI are very rare and typically caused by cancer or autoimmune disease. While very rare, acquired coagulopathy has been seen with the COVID-19 vaccine in only a handful of cases. Those reported have all been associated with Factor XIII. This is the first reported case, to our knowledge, of factor IX and XI inhibitor development after COVID vaccination.

Conclusions: Acquired coagulopathy can occur after COVID-19 vaccine inducing a spontaneous hemorrhage and should be considered as part of the etiologies of ICH.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/an-acute-cause-of-bleed-spontaneous-intracerebral-hemorrhage-due-to-acquired-factor-ix-and-xi-clotting-disorder-from-covid-19-vaccine-a-case-study/