Abstract The massive COVID-19 vaccine roll-out campaign illuminated a range of rare side effects, the most dangerous of which – vaccine-induced immune thrombotic thrombocytopenia (VITT) – is caused by adenoviral (Ad)-vectored vaccines. VITT occurrence had been linked to production of pathogenic antibodies that recognize an endogenous chemokine, platelet factor 4 (PF4). Mass spectrometry (MS)-based evaluation of the ensemble of anti-PF4 antibodies obtained from a VITT patient’s blood indicates that its major component is a monoclonal antibody. Structural characterization of this antibody reveals several unusual characteristics, such as the presence of an N -glycan in the Fab segment and high density of acidic amino acid residues in the CDR regions. A recombinant version of this antibody (RVT1) was generated by transient expression in mammalian cells based on the newly determined sequence. It captures the key properties of VITT antibodies, such as their ability to activate platelets in a PF4-dependent fashion. Homology modeling of the Fab segment reveals a well-defined polyanionic paratope, and the docking studies indicate that the polycationic segment of PF4 readily accommodates two Fab segments, cross-linking the antibodies to yield polymerized immune complexes. Their existence was verified with native MS by detecting assemblies as large as (RVT1) 3 (PF4) 2 , pointing out at FcγRIIa-mediated platelet activation as the molecular mechanism underlying VITT clinical manifestations. In addition to high PF4 affinity, RVT1 readily binds other polycationic targets, indicating a polyreactive nature of this antibody. This surprising polyspecificity not only sheds light on VITT etiology, but also opens up a range of opportunities to manage this pathology. Significance Statement Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a dangerous side effect of adenoviral-vectored vaccines that is linked to the emergence of autoantibodies recognizing platelet factor 4 (PF4). We have engineered a recombinant VITT antibody by sequencing a VITT patient-derived anti-PF4 monoclonal antibody that causes platelet activation and triggers thrombosis. This antibody was used to characterize architecture of the pathogenic immune complexes with a combination of biophysical and computational approaches, revealing the molecular mechanism of VITT. The results of this work demonstrate the critical role of electrostatics in PF4 recognition by the pathogenic antibody and the polyspecificity of the latter. Availability of the engineered VITT antibody will be invaluable for future studies aiming at understanding the general mechanistic features of autoimmune pathologies.

Reverse engineering of a pathogenic antibody reveals the molecular mechanism of vaccine-induced immune thrombotic thrombocytopenia