SARS-CoV-2-related atypical thyroiditis

The Spectrum of Thyroid Function Tests and Autoantibodies During Hospitalization and After Six Months of Discharge in COVID-19 Patients: Does COVID-19 Trigger Autoimmunity?

OBJECTIVE

The aim of the study was to investigate thyroid function test (TFT) results and anti-thyroid antibody titers in acutely infected COVID-19 patients, as well as the changes in TFT and autoantibody results during the 6-months recovery period among survivors.

PATIENTS AND DESIGN

A total of 163 adult COVID-19 patients and 124 COVID-19 survivors were evaluated in terms of TFT (thyroid stimulating hormone [TSH], free triiodothyronine [fT3], and free thyroxine [fT4]) and anti-thyroid antibodies (anti-thyroglobulin [anti-Tg] and anti-thyroid peroxidase [anti-TPO]).

RESULTS

Thyroid dysfunction was noted in 56.4% of patients on admission, including the non-thyroidal illness syndrome (NTIS) in most cases. Presence vs. absence of thyroid dysfunction on admission was associated with significantly higher rate of severe disease (p < 0.001), while severe vs. mild-to-moderate disease was associated with significantly lower serum fT3 levels (p = 0.001). Overall, 94.4% of survivors were euthyroid at the time of 6 months post-discharge, while in some patients, the post-COVID-19 recovery period was also associated with significantly increased anti-TPO titers and the presence of new-onset or persistent subclinical hypothyroidism.

CONCLUSION

This is one of the few studies to evaluate TFT and autoantibodies over a 6-month period after recovery from COVID-19. The presence of emergent or persistent subclinical hypothyroidism and the significantly increased anti-TPO titers in some patients during the convalescence period suggest the need for follow-up for development of thyroid dysfunction and autoimmunity among COVID-19 survivors.

Thyroid Function Abnormalities and Outcomes in Hospitalized Patients with COVID-19 Infection: A Cross-Sectional Study

Thyroid gland can be affected by the COVID-19 infection. The pattern of thyroid function abnormality reported in COVID-19 is variable; in addition, some drugs used in COVID-19 patients like glucocorticoids and heparin can affect the thyroid function tests (TFT). We conducted an observational, cross-sectional study of thyroid function abnormalities with thyroid autoimmune profile in COVID-19 patients with varying severity from November 2020 to June 2021. Serum FT4, FT3, TSH, anti-TPO, and anti-Tg antibodies were measured before the initiation of treatment with steroids and anti-coagulants. A total of 271 COVID-19 patients were included in the study, of which 27 were asymptomatic and remaining 158, 39, and 47 were classified to mild, moderate and severe categories, respectively, according to MoHFW, India criteria. Their mean age was 49±17 years and 64.9% were males. Abnormal TFT was present in 37.2% (101/271) patients. Low FT3, low FT4, and low TSH were present in 21.03%, 15.9% and 4.5% of patients, respectively. Pattern corresponding to sick euthyroid syndrome was the most common. Both mean FT3 and FT3/FT4 ratio decreased with increasing severity of COVID-19 illness (p=0.001). In multivariate analysis, low FT3 was associated with increased risk of mortality (OR 12.36, 95% CI: 1.23-124.19; p=0.033). Thyroid autoantibodies were positive in 58 (27.14%) patients; but it was not associated with any thyroid dysfunction. Thyroid function abnormality is common among COVID-19 patients. Both low FT3 and FT3/FT4 ratio are indicators of disease severity while low FT3 is a prognostic marker of COVID-19 associated mortality.

Clinical, biochemical features and functional outcome of patients with SARS-CoV-2-related subacute thyroiditis: a review

INTRODUCTION

SARS CoV-2 infection involves many organs and systems, including the thyroid, in which it manifests itself as subacute thyroiditis (SAT). After our first description of SAT due to SARS-CoV2 infection, other reports have confirmed the correlation between SARS-CoV-2 and SAT. We review the cases of SAT associated with COVID-19 to highlight its peculiar clinical and biochemical features, including its outcome and what it has added to our understanding of SAT.

RESULTS

We have reviewed 24 articles, for a total of 69 cases of SAT related to SARS-CoV2 infection. All had neck pain, whereas thyrotoxicosis was documented in 68/68 who had their thyroid function checked. Ultrasound, performed in 67 patients, was typical of SAT in 65 and low uptake at scintigraphy was demonstrated in all 12 evaluated patients. Patients had a prompt response to the anti-inflammatory and/or glucocorticoid therapy, as expected in SAT. The rate of hypothyroidism was higher (36.5%) in COVID-19-related SAT compared to that observed in the pre-COVID era (10%).

CONCLUSIONS

Clinical, biochemical, and instrumental features of SAT related to SARS-CoV2 are like those observed in SAT cases reported prior to COVID-19 pandemic, but it appears more severe.

SARS-CoV-2, fertility and assisted reproduction

BACKGROUND

In 2020, SARS-CoV-2 and the COVID-19 pandemic had a huge impact on the access to and provision of ART treatments. Gradually, knowledge of the virus and its transmission has become available, allowing ART activities to resume. Still, questions on the impact of the virus on human gametes and fertility remain.

OBJECTIVE AND RATIONALE

This article summarizes published data, aiming to clarify the impact of SARS-CoV-2 and the COVID-19 disease on human fertility and assisted reproduction, as well as the impact of vaccination, and from this, provide answers to questions that are relevant for people contemplating pregnancy and for health care professionals.

SEARCH METHODS

PUBMED/MEDLINE and the WHO COVID-19 database were searched from inception to 5 October 2022 with search terms focusing on 'SARS-CoV-2' and gametes, embryos, reproductive function, fertility and ART. Non-English studies and papers published prior to 2020 were excluded, as well as reviews and non-peer reviewed publications. Full papers were assessed for relevance and quality, where feasible.

OUTCOMES

From the 148 papers included, the following observations were made. The SARS-CoV-2-binding proteins, angiotensin-converting enzyme 2 (ACE2) and type II transmembrane serine protease (TMPRSS2), are expressed in the testis, but co-expression remains to be proven. There is some evidence of SARS-CoV-2 RNA in the ejaculate of COVID-19 patients with severe disease, but not in those with mild/moderate disease. SARS-CoV-2 infection can impair spermatogenesis, but this seems to resolve after one spermatogenic cycle. Testosterone levels seem to be lower during and after COVID-19, but long-term data are lacking; disease severity may be associated with testosterone levels. COVID-19 cannot be considered a sexually transmitted disease. There is no co-expression of ACE2 and TMPRSS2 in the myometrium, uterus, ovaries or fallopian tubes. Oocytes seem to have the receptors and protease machinery to be susceptible to SARS-CoV-2 infection; however, viral RNA in oocytes has not been detected so far. Women contemplating pregnancy following COVID-19 may benefit from screening for thyroid dysfunction. There is a possible (transient) impact of COVID-19 on menstrual patterns. Embryos, and particularly late blastocysts, seem to have the machinery to be susceptible to SARS-CoV-2 infection. Most studies have not reported a significant impact of COVID-19 on ovarian reserve, ovarian function or follicular fluid parameters. Previous asymptomatic or mild SARS-CoV-2 infection in females does not seem to negatively affect laboratory and clinical outcomes of ART. There are no data on the minimum required interval, if any, between COVID-19 recovery and ART. There is no evidence of a negative effect of SARS-CoV-2 vaccination on semen parameters or spermatogenesis, ovarian function, ovarian reserve or folliculogenesis. A transient effect on the menstrual cycle has been documented. Despite concerns, cross reactivity between anti-SARS-CoV-2 spike protein antibodies and Syncytin-1, an essential protein in human implantation, is absent. There is no influence of mRNA SARS-CoV-2 vaccine on patients' performance during their immediate subsequent ART cycle. Pregnancy rates post-vaccination are similar to those in unvaccinated patients.

WIDER IMPLICATIONS

This review highlights existing knowledge on the impact of SARS-CoV-2 infection or COVID-19 on fertility and assisted reproduction, but also identifies gaps and offers suggestions for future research. The knowledge presented should help to provide evidence-based advice for practitioners and couples contemplating pregnancy alike, facilitating informed decision-making in an environment of significant emotional turmoil.

Thyroid storm in a pregnant woman with COVID-19 infection: A case report and review of literatures

BACKGROUND

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been found to be responsible for the recent global pandemic known as coronavirus disease 2019 (COVID-19). SARS-CoV-2 infections not only result in significant respiratory symptoms but also cause several extrapulmonary manifestations, such as thrombotic complications, myocardial dysfunction and arrhythmia, thyroid dysfunction, acute kidney injury, gastrointestinal symptoms, neurological symptoms, ocular symptoms, and dermatological complications. We present the first documented case of thyroid storm in a pregnant woman precipitated by SARS-CoV-2.

CASE SUMMARY

A 42-year-old multiparous woman at 35 + 2 wk of gestation visited the emergency room (ER) with altered mentation, seizures, tachycardia, and high fever. The patient showed no remarkable events in the prenatal examination, and the nasopharyngeal COVID-19 polymerase chain reaction (PCR) test was positive two days before the ER visit. The results of laboratory tests, such as liver function test, serum electrolytes, blood glucose, blood urea nitrogen, and creatinine, were all within the normal ranges. However, the thyroid function test showed hyperthyroidism, and the nasopharyngeal COVID-19 PCR test was positive, as expected. No specific findings were observed on the brain computed tomography, and there were no signs of lateralization on neurological examination. Fetal heartbeat and movement were good, and there were no significant uterine contractions. The initial impression was atypical eclampsia. However, the patient's condition worsened, and a cesarean section was performed under general anesthesia; a healthy boy was delivered, and 12 h after delivery, the patient's seizures disappeared and consciousness was restored. The patient was referred to an endocrinologist for hyperthyroidism, and a thyroid storm with Graves' disease was diagnosed. Here, SARS-CoV-2 was believed to be the trigger for the thyroid storm, considering that the patient tested positive for COVID-19 two days before the seizures.

CONCLUSION

In pregnant women presenting with seizures or changes in consciousness, the possibility of a thyroid storm should be considered. There are various causes for a thyroid storm, but given the recent pandemic, it is necessary to bear in mind that the thyroid storm may be precipitated by COVID-19.

Impact of the COVID-19 pandemic on the incidence, seasonal distribution, and characteristics of subacute thyroiditis

PURPOSE

An increasing number of cases of subacute thyroiditis (SAT) related to the coronavirus disease 2019 (COVID-19) and its vaccines continue to be published. The aim of this study was to investigate any change in the incidence and characteristics of SAT by comparing the pre-pandemic and pandemic periods.

METHODS

This retrospective, single-center study included 432 newly-diagnosed SAT patients between January 2018 and December 2021. The annual frequency of SAT was calculated as the number of newly-diagnosed SAT cases divided by the total number of outpatients that year.

RESULTS

The frequencies of newly-diagnosed SAT were 0.136% in 2018, 0.127% in 2019, 0.157% in 2020, and 0.114% in 2021 (p = 0.19). While SAT patients were clustered in the autumn (35.1%) in 2018 and 2019, it was found that this cluster shifted to the winter (33.0%) in 2020 and 2021, in parallel with COVID-19 case peaks (p = 0.017). The patients were separated into two groups as pre-COVID-19 pandemic SAT (n = 272) and COVID-19 pandemic SAT (n = 160). The mean ages of the groups were similar. There were more male patients in the COVID-19 pandemic SAT group than in the pre-pandemic group (30.6% vs. 18.7%, p = 0.005). Frequencies of overt hyperthyroidism and median free-thyroxine levels were significantly higher in the COVID-19 pandemic SAT group (p = 0.029, p = 0.001). Treatment modalities, recurrence rates, and permanent hypothyroidism were similar in both groups.

CONCLUSION

With the COVID-19 pandemic, although there was a change in seasonal variation of SAT and an increase in the number of male patients, there was no change in the incidence and clinical course of SAT.

Viruses and Endocrine Diseases

Viral infections have been frequently associated with physiological and pathological changes in the endocrine system for many years. The numerous early and late endocrine complications reported during the current pandemic of coronavirus disease 2019 (COVID-19) reinforce the relevance of improving our understanding of the impact of viral infections on the endocrine system. Several viruses have been shown to infect endocrine cells and induce endocrine system disturbances through the direct damage of these cells or through indirect mechanisms, especially the activation of the host antiviral immune response, which may lead to the development of local or systemic inflammation or organ-specific autoimmunity. In addition, endocrine disorders may also affect susceptibility to viral infections since endocrine hormones have immunoregulatory functions. This review provides a brief overview of the impact of viral infections on the human endocrine system in order to provide new avenues for the control of endocrine diseases.

A Literature Review on SARS-CoV-2 and Other Viruses in Thyroid Disorders: Environmental Triggers or No-Guilty Bystanders?

A growing number of findings indicate a relationship between COVID-19 infection and thyroid dysfunction. This association is also strengthened by knowledge on the potential of viral infections to trigger thyroid disorders, although the exact underlying pathogenetic process remains to be elucidated. This review aimed to describe the available data regarding the possible role of infectious agents, and in particular of SARS-CoV-2, in the development of thyroid disorders, summarizing the proposed mechanisms and levels of evidence (epidemiological, serological or direct presence of the viruses in the thyroid gland) by which the infection could be responsible for thyroid abnormalities/diseases. Novel data on the association and mechanisms involved between SARS-CoV-2 vaccines and thyroid diseases are also discussed. While demonstrating a clear causal link is challenging, numerous clues at molecular and cellular levels and the large amount of epidemiological data suggest the existence of this relationship. Further studies should be taken to further investigate the true nature and strength of this association, to help in planning future preventive and therapeutic strategies for more personal and targeted care with attention to the underlying causes of thyroid dysfunction.

Endocrine Disorders and COVID-19

The multifaceted interaction between coronavirus disease 2019 (COVID-19) and the endocrine system has been a major area of scientific research over the past two years. While common endocrine/metabolic disorders such as obesity and diabetes have been recognized among significant risk factors for COVID-19 severity, several endocrine organs were identified to be targeted by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). New-onset endocrine disorders related to COVID-19 were reported while long-term effects, if any, are yet to be determined. Meanwhile, the "stay home" measures during the pandemic caused interruption in the care of patients with pre-existing endocrine disorders and may have impeded the diagnosis and treatment of new ones. This review aims to outline this complex interaction between COVID-19 and endocrine disorders by synthesizing the current scientific knowledge obtained from clinical and pathophysiological studies, and to emphasize considerations for future research.

Increased prevalence of autoimmune thyroid disease after COVID-19: A single-center, prospective study

INTRODUCTION

Thyroid dysfunctions associated with SARS-CoV-2 acute infection have been extensively described since the beginning of COVID-19 pandemics. Conversely, few data are available on the occurrence of thyroid autoimmunity after COVID-19 resolution. We assessed the prevalence of autoimmune thyroid disease (ATD) and thyroid dysfunctions in COVID-19 survivors three months after hospital admission.

DESIGN AND METHODS

Single-center, prospective, observational, cohort study performed at ASST Papa Giovanni XXIII Hospital, Bergamo, Italy. 599 COVID-19 survivors were prospectively evaluated for thyroid function and autoimmunity thyroperoxidase antibodies (TPOAb), thyroglobulin antibodies (TgAb). When a positive antibody concentration was detected, thyroid ultrasound was performed. Multiple logistic regression model was used to estimate the association between autoimmunity and demographic characteristics, respiratory support, and comorbidities. Autoimmunity results were compared to a cohort of 498 controls referred to our Institution for non-thyroid diseases before the pandemic onset. A sensitivity analysis comparing 330 COVID-19 patients with 330 age and sex-matched controls was performed.

RESULTS

Univariate and multivariate analysis found that female sex was positively associated (OR 2.01, SE 0.48, p = 0.003), and type 2 diabetes (T2DM) was negatively associated (OR 0.36, SE 0.16, p = 0.025) with thyroid autoimmunity; hospitalization, ICU admission, respiratory support, or COVID-19 treatment were not associated with thyroid autoimmunity (p > 0.05). TPOAb prevalence was greater in COVID-19 survivors than in controls: 15.7% vs 7.7%, p = 0.002. Ultrasonographic features of thyroiditis were present in 94.9% of the evaluated patients with positive antibodies. TSH was within the normal range in 95% of patients.

CONCLUSIONS

Autoimmune thyroid disease prevalence in COVID-19 survivors was doubled as compared to age and sex-matched controls, suggesting a role of SARS-CoV-2 in eliciting thyroid autoimmunity.

IMPACT OF COVID-19 ON THYROID FUNCTION: EVIDENCE FROM IRAN

Context

We assessed the association between the severity of COVID-19 and the thyroid function, and the relationship of thyroid hormones with inflammatory markers in COVID-19 patients.

Subjects and methods

This observational study contained 95 COVID-19 patients. The covariates of interest included the thyroid-stimulating hormone (TSH) and the total form of thyroid hormones thyroxine and triiodothyronine. Furthermore, the inflammatory markers including C-reactive protein, erythrocyte sedimentation rate, lactate dehydrogenase (LDH), and lymphocyte were measured. To analyze the data, the t-test, the nonparametric test for comparing the medians, and the Spearman correlation were used.

Results

The median (interquartile range) of ages was equal to 53 (41-66) years old, including 54 men (56.8%). As the severity of COVID-19 progressed from moderate to severe, increasing, though non-significant, trends of thyroid dysfunction were observed, the most remarkable for TSH. The only significant association between thyroid hormones and inflammatory markers was a Spearman correlation of -0.28 between TSH and LDH. Moreover, a direct association was found between the severity of COVID-19 and the LDH levels (p-value<0.001).

Conclusions

A direct relation between the severity of COVID-19 and the LDH level and a reverse association between the LDH level and the thyroid hormone, TSH was obtained.

Emerging trends and hot spots in subacute thyroiditis research from 2001 to 2022: A bibliometric analysis

BACKGROUND

Subacute thyroiditis (SAT) is the most prevalent self-limiting thyroid disease that causes pain, accounting for about 5% of all clinical thyroid disorders. Numerous clinically noteworthy results have been published in this area over the last 20 years. However, no article has comprehensively assessed the relevant literature yet. We conducted a bibliometric analysis of SAT to provide light on the dynamic nature of scientific advancement and aid researchers in gaining a global perspective while examining research core themes and hotspots.

METHODS

SAT-related articles and reviews from 2001 to 2022 were retrieved from the Science Citation Index-Expanded of Web of Science Core Collection (WoSCC). We analyzed current research trends and hotspots in this area using CiteSpace and Vosviewer.

RESULTS

A total of 568 studies associated with SAT research were published in 282 academic journals by 2,473 authors in 900 institutions from 61 countries/regions. The United States was a crucial link in inter-country/region collaboration and was the most frequently involved country in international cooperation. The University of Missouri System was the top organization, and Braley-Mullen H. was the most productive researcher. Thyroid published the most papers, with 36 publications. The most co-cited article was "Clinical features and outcome of subacute thyroiditis in an incidence cohort: Olmsted County, Minnesota, study" (by Fatourechi V., 2003). The clustered network and timeline view of keywords showed that the prevalence, diagnosis, and treatment of SAT were the research core themes during the past 20 years. Analysis of keyword bursts indicated that the clinical characteristic and the influence of COVID-19 on SAT appeared to be the current research hotspots.

CONCLUSION

This bibliometric analysis conducted a thorough review of the SAT research. The clinical characteristics and the genetic background of SAT under the influence of COVID-19 are current research hotspots. However, there is still a need for further study and global collaboration. Our findings can aid researchers in understanding the current status of SAT research and immediately pinpoint new directions for further investigation.

A prospective follow-up of thyroid volume and thyroiditis features on ultrasonography among survivors of predominantly mild to moderate COVID-19

Background

We previously showed that higher SARS-CoV-2 viral load correlated with smaller thyroid volumes among COVID-19 survivors at 2 months after acute COVID-19. Our current follow-up study evaluated the evolution of thyroid volumes and thyroiditis features within the same group of patients 6 months later.

Methods

Adult COVID-19 survivors who underwent thyroid ultrasonography 2 months after infection (USG1) were recruited for follow-up USG 6 months later (USG2). The primary outcome was the change in thyroid volume. We also reassessed thyroiditis features on USG, thyroid function and anti-thyroid antibodies.

Results

Fifty-four patients were recruited (mean age 48.1 years; 63% men). The mean thyroid volume increased from USG1 to USG2 (11.9 ± 4.8 to 14.5 ± 6.2 mL, p < 0.001). Thirty-two patients (59.3%) had significant increase in thyroid volume by ≥15%, and they had a median increase of +33.3% (IQR: +20.0% to +45.0%). Multivariable logistic regression analysis showed that only higher baseline SARS-CoV-2 viral load independently correlated with significant thyroid volume increase on USG2 (p = 0.022). Among the seven patients with thyroiditis features on USG1, six (85.7%) had the features resolved on USG2. None had new thyroiditis features on USG2. All abnormal thyroid function during acute COVID-19 resolved upon USG1 and USG2.

Conclusion

Most COVID-19 survivors had an increase in thyroid volume from early convalescent phase to later convalescent phase. This increase correlated with high initial SARS-CoV-2 viral load. Together with the resolution of thyroiditis features, these may suggest a transient direct atrophic effect of SARS-CoV-2 on the thyroid gland with subsequent recovery of thyroid volume and thyroiditis features.

Thyrotropin Levels in Patients with Coronavirus Disease 2019: Assessment during Hospitalization and in the Medium Term after Discharge

BACKGROUND

The objectives of this study were (1) to compare TSH levels between inpatients with critical versus non-critical coronavirus disease 19 (COVID-19), and (2) to describe the status of TSH levels three months after hospitalization.

METHODS

We collected data on adult patients hospitalized with COVID-19 at Amiens University Hospital. We compared TSH levels between inpatients with critical (intensive care unit admission and/or death) versus non-critical COVID-19. Thereafter, survivors were invited to return for a three-month post-discharge visit where thyroid function tests were performed, regardless of the availability of TSH measurement during hospitalization.

RESULTS

Among 448 inpatients with COVID-19, TSH assay data during hospitalization were available for 139 patients without prior thyroid disease. Patients with critical and non-critical forms of COVID-19 did not differ significantly with regard to the median (interquartile range) TSH level (0.96 (0.68-1.71) vs. 1.27 mIU/L (0.75-1.79), p = 0.40). Abnormal TSH level was encountered in 17 patients (12.2%); most of them had subclinical thyroid disease. TSH assay data at the three-month post-discharge visit were available for 151 patients without prior thyroid disease. Only seven of them (4.6%) had abnormal TSH levels. Median TSH level at the post-discharge visit was significantly higher than median TSH level during hospitalization.

CONCLUSIONS

Our findings suggest that COVID-19 is associated with a transient suppression of TSH in a minority of patients regardless of the clinical form. The higher TSH levels three months after COVID-19 might suggest recovery from non-thyroidal illness syndrome.

Investigating thyroid dysfunction in the context of COVID-19 infection

COVID-19 is a contagious viral infection caused by severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2). One of the key features of COVID-19 infection is inflammation. There is increasing evidence pointing to an association between cytokine storm and autoimmunity. One autoimmune disease of interest in connection to COVID-19 is hyperthyroidism. COVID-19 has been shown to decrease TSH levels and induce thyrotoxicosis, destructive thyroiditis, and de novo Graves' disease. It has also been suggested that the immune response against SARS-CoV-2 antigens following vaccination can cross-react through a mechanism called molecular mimicry which can elicit autoimmune reactivity, potentially leading to potential thyroid disease post vaccine. However, if the COVID-19 vaccine is linked to reduced COVID-19 related serious disease, it could potentially play a protective role against post COVID-19 hyperthyroidism (de novo disease and exacerbations). Further studies investigating the complex interplay between COVID-19 or COVID-19 vaccine and thyroid dysfunction can help provide substantial evidence and potential therapeutic targets that can alter prognosis and improve COVID-19 related outcomes in individuals with or without preexisting thyroid disease.

Free triiodothyronine levels and age influences the metabolic profile and COVID-19 severity parameters in euthyroid and levothyroxine-treated patients

Metabolic reprogramming is required to fight infections and thyroid hormones are key regulators of metabolism. We have analyzed in hospitalized COVID-19 patients: 40 euthyroid and 39 levothyroxine (LT4)-treated patients in the ward and 29 euthyroid and 9 LT4-treated patients in the intensive care unit (ICU), the baseline characteristics, laboratory data, thyroid-stimulating hormone (TSH), free thyroxine (FT4), free triiodothyronine (FT3), the FT3/FT4 ratio, 11 antiviral cytokines and 74 metabolomic parameters. No evidence for significant differences between euthyroid and LT4-treated patients were found in the biochemical, metabolomic and cytokines parameters analyzed. Only TSH (p=0.009) and ferritin (p=0.031) showed significant differences between euthyroid and LT4-treated patients in the ward, and TSH (p=0.044) and FT4 (p=0.012) in the ICU. Accordingly, severity and mortality were similar in euthyroid and LT4-treated patients. On the other hand, FT3 was negatively related to age (p=0.012), independently of sex and body mass index in hospitalized COVID-19 patients. Patients with low FT3 and older age showed a worse prognosis and higher levels of the COVID-19 severity markers IL-6 and IL-10 than patients with high FT3. IL-6 negatively correlated with FT3 (p=0.023) independently of age, body mass index and sex, whereas IL-10 positively associated with age (p=0.035) independently of FT3, body mass index and sex. A metabolomic cluster of 6 parameters defined low FT3 ward patients. Two parameters, esterified cholesterol (p=4.1x10-4) and small HDL particles (p=6.0x10-5) correlated with FT3 independently of age, body mass index and sex, whereas 3-hydroxybutyrate (p=0.010), acetone (p=0.076), creatinine (p=0.017) and high-density-lipoprotein (HDL) diameter (p=8.3x10-3) were associated to FT3 and also to age, with p-values of 0.030, 0.026, 0.017 and 8.3x10-3, respectively. In conclusion, no significant differences in FT3, cytokines, and metabolomic profile, or in severity and outcome of COVID-19, were found during hospitalization between euthyroid patients and hypothyroid patients treated with LT4. In addition, FT3 and age negatively correlate in COVID-19 patients and parameters that predict poor prognosis were associated with low FT3, and/or with age. A metabolomic cluster indicative of a high ketogenic profile defines non-critical hospitalized patients with low FT3 levels.

Development of a prediction score (ThyroCOVID) for identifying abnormal thyroid function in COVID-19 patients

PURPOSE

Thyroid dysfunction in COVID-19 carries clinical and prognostic implications. In this study, we developed a prediction score (ThyroCOVID) for abnormal thyroid function (TFT) on admission amongst COVID-19 patients.

METHODS

Consecutive COVID-19 patients admitted to Queen Mary Hospital were prospectively recruited during July 2020-May 2021. Thyroid-stimulating hormone (TSH), free thyroxine (fT4) and free triiodothyronine (fT3) were measured on admission. Multivariable logistic regression analysis was performed to identify independent determinants of abnormal TFTs. ThyroCOVID was developed based on a clinical model with the lowest Akaike information criteria.

RESULTS

Five hundred and forty six COVID-19 patients were recruited (median age 50 years, 45.4% men, 72.9% mild disease on admission). 84 patients (15.4%) had abnormal TFTs on admission. Patients with abnormal TFTs were more likely to be older, have more comorbidities, symptomatic, have worse COVID-19 severity, higher SARS-CoV-2 viral loads and more adverse profile of acute-phase reactants, haematological and biochemical parameters. ThyroCOVID consisted of five parameters: symptoms (malaise), comorbidities (ischaemic heart disease/congestive heart failure) and laboratory parameters (lymphocyte count, C-reactive protein, and SARS-CoV-2 cycle threshold values). It was able to identify abnormal TFT on admission with an AUROC of 0.73 (95% CI 0.67-0.79). The optimal cut-off of 0.15 had a sensitivity of 75.0%, specificity of 65.2%, negative predictive value of 93.5% and positive predictive value of 28.1% in identifying abnormal TFTs on admission amongst COVID-19 patients.

CONCLUSION

ThyroCOVID, a prediction score to identify COVID-19 patients at risk of having abnormal TFT on admission, was developed based on a cohort of predominantly non-severe COVID-19 patients.

Current concepts regarding Graves' orbitopathy

Graves' orbitopathy (GO) is an orbital autoimmune disorder and the main extrathyroidal manifestation of Graves' disease, the most common cause of hyperthyroidism. GO affects about 30% of Graves' patients, although fewer than 10% have severe forms requiring immunosuppressive treatments. Management of GO requires a multidisciplinary approach. Medical therapies for active moderate-to-severe forms of GO (traditionally, high-dose glucocorticoids) often provide unsatisfactory results, and subsequently surgeries are often needed to cure residual manifestations. The aim of this review is to provide an updated overview of current concepts regarding the epidemiology, pathogenesis, assessment, and treatment of GO, and to present emerging targeted therapies and therapeutic perspectives. Original articles, clinical trials, systematic reviews, and meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, Graves' orbitopathy, thyroid eye disease, glucocorticoids, orbital radiotherapy, rituximab, cyclosporine, azathioprine, teprotumumab, TSH-receptor antibody, smoking, hyperthyroidism, hypothyroidism, thyroidectomy, radioactive iodine, and antithyroid drugs. Recent studies suggest a secular trend toward a milder phenotype of GO. Standardized assessment at a thyroid eye clinic allows for a better general management plan. Treatment of active moderate-to-severe forms of GO still relies in most cases on high-dose systemic-mainly intravenous-glucocorticoids as monotherapy or in combination with other therapies-such as mycophenolate, cyclosporine, azathioprine, or orbital radiotherapy-but novel biological agents-including teprotumumab, rituximab, and tocilizumab-have achieved encouraging results.

The Prognostic Properties of Thyroid Disorders, Hypothyroidism, and Hyperthyroidism in Predicting COVID-19 Poor Outcomes: A Systematic Review and Diagnostic Meta-analysis

Purpose

The relationship between thyroid metabolism and coronavirus disease 2019 (COVID-19) inflammation has been extensively investigated. This meta-analysis aimed to evaluate the prognostic properties of unspecified thyroid disorders, hypothyroidism and hyperthyroidism for predicting poor COVID-19 outcomes.

Methods

We conducted systematic literature searching through multiple databases-PubMed, EBSCO and CENTRAL up until 27 September 2021. The main exposure was unspecified thyroid disorders, hypothyroidism or hypothyroidism on-admission status. The outcome of interest was the COVID-19 composite poor outcome that comprises severity, mortality, ICU admission and hospitalisation.

Results

There were 24517 patients from 20 studies. Meta-analysis showed that thyroid disorder, regardless of its type, was associated with COVID-19 poor outcome (OR 2.92 (95% CI 2.09 - 4.08), P < 0.001; I2 = 71%, P < 0.001). Unspecified thyroid disorder has a sensitivity of 0.17 (0.08-0.33), specificity of 0.94 (0.88-0.97) and Area Under Curve (AUC) of 0.66. Hypothyroidism has a sensitivity of 0.24 (0.12-0.42), specificity of 0.92 (0.87-0.96) and AUC of 0.77. Hyperthyroidism has a sensitivity of 0.05 (0.02-0.11), specificity of 0.98 (0.88-1.00) and AUC of 0.36. In this pooled analysis, the posttest probability of unspecified thyroid disease, hypothyroidism and hyperthyroidism were 42%, 27% and 8% for poor outcomes, respectively.

Conclusion

Thyroid disorders are associated with poor COVID-19 prognosis.

Comorbidities, Associated Diseases, and Risk Assessment in COVID-19-A Systematic Review

It is considered that COVID-19's pandemic expansion is responsible for the particular increase in deaths, especially among the population with comorbidities. The health system is often overwhelmed by the large number of cases of patients addressing it, by the regional limitation of funds, and by the gravity of cases at subjects suffering from this pathology. Several associated conditions including diabetes, cardiovascular illnesses, obesity, persistent lung condition, neurodegenerative diseases, etc., increase the mortality risk and hospitalization of subjects suffering from COVID-19. The rapid identification of patients with increased risk of death from the SARS-CoV-2 virus, the stratification in accordance with the risk and the allocation of human, financial, and logistical resources in proportion must be a priority for health systems worldwide.

Association of thyroid dysfunction and COVID-19: A systematic review and meta-analysis

This systematic review and meta-analysis was conducted to evaluate the effect of COVID-19 on thyroid function and the role of thyroid hormones alterations in predicting the severity of COVID-19. Online databases, including Scopus, Medline/PubMed, EMBASE, Google Scholar, and Cochrane were searched up to August 2, 2022. After screening titles, abstracts, and full manuscripts, respectively, 30 reports were enrolled. The risk of bias (ROB) was evaluated using the QUADAS-2 tool. In addition, odds ratio (OR) and hazard ratio (HR) analysis for assessing the OR of abnormal thyroid function tests (TFT) in predicting the COVID-19 severity and poor outcomes. Among 30 enrolled studies, ROB of the current study is estimated low to moderate. The average number of patients in each study was 325 (range: 40-3,703), with an overall mean age of 57.6, and the female proportion of 40.4%. Overall, the pooled analysis showed that the prevalence of thyroid dysfunction among 9,707 COVID-19 cases was 15%. Among mild to moderate COVID-19 patients, 6.2% had abnormal TFT, and among patients who experienced severe to critical COVID-19, 20.8% had abnormal TFT. The pooled OR for abnormal TFT and the severity of COVID-19 obtained from 3,865 COVID-19 patients was 3.77 (2.03, 6.99). The pooled HR of TSH level of COVID-19 mortality was 1.57 (0.91, 2.72). Our results demonstrate a high prevalence of thyroid dysfunction in COVID-19, and that among patients severe cases had a 3.77-fold higher risk of abnormal TFT compared to mild to moderate COVID-19. Further studies are required to evaluate the longer-term prognostic role of thyroid dysfunction in severe COVID-19, and investigate potential therapeutic strategies.

Endocrine Aspects of ICU-Hospitalized COVID-19 Patients

The unprecedented scale of the current SARS-CoV-2/COVID-19 pandemic has led to an extensive—yet fragmented—assessment of its endocrine repercussions; in many reports, the endocrine aspects of COVID-19 are lumped together in intensive care unit (ICU) patients and non-ICU patients. In this brief review, we aimed to present endocrine alterations in ICU-hospitalized patients with COVID-19. There are tangible endocrine disturbances that may provide fertile ground for COVID-19, such as preexisting diabetes. Other endocrine disturbances accompany the disease and more particularly its severe forms. Up to the time of writing, no isolated robust endocrine/hormonal biomarkers for the prognosis of COVID-19 have been presented. Among those which may be easily available are admission glycemia, thyroid hormones, and maybe (OH)₂₅-vitamin D3. Their overlap among patients with severe and less severe forms of COVID-19 may be considerable, so their levels may be indicative only. We have shown that insulin-like growth factor 1 may have prognostic value, but this is not a routine measurement. Possibly, as our current knowledge is expanding, the inclusion of selected routine endocrine/hormonal measurements into artificial intelligence/machine learning models may provide further information.

New-onset myasthenia gravis after mRNA SARS-CoV-2 vaccination: a case series

Background

Myasthenia gravis (MG) is an autoimmune disease that targets acetylcholine receptor (AChR) of the neuromuscular junction. New-onset MG after SARS-CoV-2 vaccination has rarely been reported.

Case presentation

We report about three patients who presented new-onset myasthenia gravis after receiving mRNA SARS-CoV-2 vaccination. The patients were all males and older than 55 years. All the patients presented with ocular and bulbar symptoms. The interval between vaccine administration and MG onset ranged from 3 days after the first dose to 10 days after the second dose. All the patients had elevated serum AChR antibodies and responded to pyridostigmine. Two out of three patients were successfully treated with IVIG or plasma exchange and with long-term immunosuppression.

Conclusions

MG is a rare disease; clinicians should be aware of possible new-onset MG after SARS-CoV-2 vaccination, especially with the current recommendation of booster doses. The hyperstimulation of the innate immune system or the exacerbation of a subclinical pre-existing MG could be possible explanations.

Gut Microbiota Dynamics in Relation to Long-COVID-19 Syndrome: Role of Probiotics to Combat Psychiatric Complications

Increasing numbers of patients who recover from COVID-19 report lasting symptoms, such as fatigue, muscle weakness, dementia, and insomnia, known collectively as post-acute COVID syndrome or long COVID. These lasting symptoms have been examined in different studies and found to influence multiple organs, sometimes resulting in life-threating conditions. In this review, these symptoms are discussed in connection to the COVID-19 and long-COVID-19 immune changes, highlighting oral and psychiatric health, as this work focuses on the gut microbiota’s link to long-COVID-19 manifestations in the liver, heart, kidney, brain, and spleen. A model of this is presented to show the biological and clinical implications of gut microbiota in SARS-CoV-2 infection and how they could possibly affect the therapeutic aspects of the disease. Probiotics can support the body’s systems in fighting viral infections. This review focuses on current knowledge about the use of probiotics as adjuvant therapies for COVID-19 patients that might help to prevent long-COVID-19 complications.

Schilddrüse und SARS-CoV-2

Es gibt verschiedene Wechselwirkungen zwischen einer SARS-CoV-2-Infektion und der Schilddrüse, bidirektional in beide Richtungen: Bei einer schweren COVID-19-Infektion sind Veränderungen der Schilddrüsenhormonspiegel ein Marker für eine schlechtere Prognose. SARS-CoV‑2 scheint sowohl direkt mit Thyreozyten zu interagieren als auch das Immunsystem zu modulieren und Immunthyreopathien triggern zu können. Bereits 2020 wurde die „SARS-CoV-2-assoziierte Thyreoiditis“ bei Patienten mit COVID-19 beschrieben, die ähnlich einer subakuten Thyreoiditis verläuft, allerdings typischerweise schmerzlos. Es gibt inzwischen verschiedenste Berichte über das Auftreten einer chronischen Immunthyreoiditis und eines Morbus Basedow sowohl nach Virusinfektion als auch nach Impfung. Eine bestehende Schilddrüsenerkrankung scheint weder mit einem höheren Risiko für eine SARS-CoV-2-Infektion noch mit einem schwereren Krankheitsverlauf assoziiert zu sein. In der vorliegenden Arbeit wird der derzeitige Wissensstand bezüglich Schilddrüse und SARS-CoV‑2 zusammengefasst.

Preliminary Guidelines for the Clinical Evaluation and Management of Long COVID

Long-lasting coronavirus disease 2019 (COVID-19) symptoms beyond 12 weeks, the so-called 'long COVID' have been increasingly reported worldwide. Long COVID can be manifested in various forms, and there is an increasing demand for proper assessment and management. However, it is challenging when trying to determine the best-practice standards of care based on the current evidence because there is no internationally agreed clinical definition or clear treatment pathway. Therefore, the present guidelines have been drafted to provide advice on diagnosis and management based on the latest updated available evidence and the consensus of expert opinion. So far, no standard test and drug treatment can be strongly recommended for patients with long COVID because of a lack of evidence. The present guidelines provide advice based on 12 key questions, including appropriate interventions for long COVID that can be used in clinical practice. Continuous careful observation and studies related to long COVID are needed for the long-term impact of COVID-19 and proper management for long COVID to be determined.

COVID-19 and Thyroid Function: A Bi-Directional Two-Sample Mendelian Randomization Study

Background: Thyroid dysfunction has been observed among some patients with coronavirus disease (COVID-19). It is unclear whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (or its severity) leads to the development of thyroid dysfunction, or vice versa. In this study, we examined the bi-directional causal relationship between host genetic liability to three COVID-19 phenotypes (including SARS-CoV-2 infection, hospitalized and severe COVID-19) and three thyroid dysfunction traits (including hyperthyroidism, hypothyroidism, and autoimmune thyroid disease [AITD]) and three continuous traits of thyroid hormones (including thyrotropin [TSH] and free thyroxine [fT4] within reference range, and TSH in full range). Methods: Summary statistics from the largest available meta-analyses of human genome-wide association studies were retrieved for the following variables: SARS-CoV-2 infection (n = 1,348,701), COVID-19 hospitalization (n = 1,557,411), severe COVID-19 (n = 1,059,456), hyperthyroidism (n = 51,823), hypothyroidism (n = 53,423), AITD (n = 755,406), TSH within reference range (n = 54,288), fT4 within reference range (n = 49,269), and TSH in full range (n = 119,715). Using a two-sample Mendelian randomization (MR) approach, the inverse-variance weighted (IVW) method was adopted as the main MR analysis. Weighted median, contamination mixture, MR-Egger, and MR pleiotropy residual sum and outlier (MR-PRESSO) methods were applied as sensitivity analyses. Results: Host genetic susceptibility to SARS-CoV-2 infection was causally associated with hypothyroidism in the main IVW analysis (per doubling in prevalence of SARS-CoV-2 infection, odds ratio [OR] = 1.335; 95% confidence interval [CI]: 1.167-1.526; p = 2.4 × 10^-5, surpassing the Bonferroni multiple-testing threshold). Similar causal estimates were observed in the sensitivity analyses (weighted median: OR = 1.296; CI: 1.066-1.575; p = 9 × 10^-3; contamination mixture: OR = 1.356; CI: 1.095-1.818; p = 0.013; MR-Egger: OR = 1.712; CI: 1.202-2.439; p = 2.92 × 10^-3, and MR-PRESSO: OR = 1.335; CI: 1.156-1.542; p = 5.73 × 10^-4). Host genetic liability to hospitalized or severe COVID-19 was not associated with thyroid dysfunction or thyroid hormone levels. In the reverse direction, there was no evidence to suggest that genetic predisposition to thyroid dysfunction or genetically determined thyroid hormone levels altered the risk of the COVID-19 outcomes. Conclusions: This bi-directional MR study supports that host response to SARS-CoV-2 viral infection plays a role in the causal association with increased risk of hypothyroidism. Long-term follow-up studies are needed to confirm the expected increased hypothyroidism risk.

The role of PET/CT in thyroid autoimmune diseases

Autoimmune thyroid diseases (AITD) are a heterogeneous group of disorders. They include, in particular, Graves' disease and Hashimoto's thyroiditis with a wide range of different functional status ranging from subclinical biochemical abnormalities to severe hyperthyroidism or severe hypothyroidism respectively. Furthermore, other conditions more frequently infectious or drug related can cause an immune reaction in the thyroid tissue. In AITDs, positron emission tomography/computed tomography (PET/CT) does not play a primary role for disease diagnosis or management, but accidental findings can occur in both symptomatic and asymptomatic patients, and they should be recognized and well interpreted. A comprehensive literature search of the PubMed databases was conducted to identify papers (systematic review, prospective and retrospective study, case report) evaluating the role of PET/CT in thyroid autoimmune diseases. Thyroid diffuse uptake of 18F-fluoro-2-deoxy-2-d-glucose ([18F]FDG) has been shown to be frequently associated with AITDs, but also with immune-induced thyroid disorders related to SARS-CoV-2 or immunotherapy, while malignant lesions more often have a focal aspect. Other radiopharmaceuticals as [68Ga]-DOTA-peptides, [68Ga]-fibroblast activation protein inhibitors (FAPIs) and [68Ga]-prostate specific membrane antigen ([68Ga]-PSMA) showed similar findings. In conclusion, PET/CT scan in AITDs does not play a primary role in the diagnosis, but the occasional finding of a thyroid uptake must always be described in the report and possibly investigated for a better patient's management.

Subacute thyroiditis with liver dysfunction following coronavirus disease 2019 (COVID-19) vaccination: report of two cases and a literature review

Subacute thyroiditis is a transient inflammatory thyroid disease characterized by neck pain, fever, and typical symptoms associated with thyrotoxicosis. The incidence of subacute thyroiditis is higher in female than in male, and susceptibility is prominent in the 30-50-year age range. The variety of case reports on subacute thyroiditis associated with coronavirus disease 2019 (COVID-19) appears to be increasing, and subacute thyroiditis following COVID-19 vaccination has recently been reported. Herein, we report two cases of subacute thyroiditis that developed after receiving the COVID-19 mRNA vaccine, one of which exhibited remarkable liver dysfunction. The mechanism underlying the development of post-vaccination subacute thyroiditis remains unknown; however, one theory suggests that adjuvants contained in vaccines may play a role in triggering diverse autoimmune and inflammatory responses. Another possibility is the potential cross-reactivity between the coronavirus spike protein target produced by the mRNA vaccine and thyroid cell antigens. Common side effects of the COVID-19 vaccine include pain at the injection site, fever, fatigue, headache, muscle pain, chills, and nausea. These symptoms are usually resolved within a few days. Subacute thyroiditis may present symptoms similar to those of short-term vaccination side effects or exhibit non-specific symptoms, potentially leading to misdiagnosis or underdiagnosis. Therefore, clinicians should be aware of the possible development of subacute thyroiditis after COVID-19 vaccination.

COVID-19 Infection-Related Thyrotoxic Hypokalemic Periodic Paralysis

SARS-CoV-2 infection induces the dysfunction of many organs including the thyroid gland through the role of ACE2 receptors as well as the consequences of the cytokine storm. Thyroid diseases such as subacute thyroidism, Graves' disease, thyrotoxicosis, and Hashimoto's thyroiditis have been documented in patients with SARS-CoV-2 infection. However, there are limited reports about the consequences of SARS-CoV-2 infection-related thyroid complications. We describe a case of man who was admitted to the emergency department due to repeated lower limb weakness since diagnosed with COVID-19. He had refractory hypokalemia and was treated with potassium replacement therapy for 2 months. However, the complaints continued. The patient has no history of thyroid disease, yet the laboratory result showed hyperthyroidism. Accordingly, he received oral thiamazole. As the laboratory parameters of the thyroid hormones improved, potassium levels returned to normal and the limb weakness stopped. This unusual thyroid complication should be considered in SARS-CoV-2 infection. The prompt diagnosis and appropriate therapy can reduce the burden of the disease.

Role of Nuclear Factor Erythroid 2 (Nrf2) in the Recovery of Long COVID-19 Using Natural Antioxidants: A Systematic Review

Coronavirus disease 2019 (COVID-19) is an infectious disease with approximately 517 million confirmed cases, with the average number of cases revealing that patients recover immediately without hospitalization. However, several other cases found that patients still experience various symptoms after 3–12 weeks, which is known as a long COVID syndrome. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can activate nuclear factor kappa beta (NF-κβ) and unbind the nuclear factor erythroid 2-related factor 2 (Nrf2) with Kelch-like ECH-associated protein 1 (Keap1), causing inhibition of Nrf2, which has an important role in antioxidant response and redox homeostasis. Disrupting the Keap1–Nrf2 pathway enhances Nrf2 activity, and has been identified as a vital approach for the prevention of oxidative stress and inflammation. Hence, natural antioxidants from various sources have been identified as a promising strategy to prevent oxidative stress, which plays a role in reducing the long COVID-19 symptoms. Oxygen-rich natural antioxidant compounds provide an effective Nrf2 activation effect that interact with the conserved amino acid residues in the Keap1-binding pocket, such as Ser602, Ser363, Ser508, and Ser555. In this review, the benefits of various natural antioxidant compounds that can modulate the Nrf2 signaling pathway, which is critical in reducing and curing long COVID-19, are highlighted and discussed.

New-onset Graves' disease following SARS-CoV-2 vaccination: a case report

A 22-year-old male with a history of ulcerative colitis and nephrotic syndrome treated with immunomodulatory agents including vedolizumab and mycophenolic acid developed hyperthyroidism 2 weeks following the first administration of BNT162b2 vaccine (Pfizer-BioNTech COVID-19 vaccine). Graves' disease (GD) was diagnosed based on the elevated thyrotropin-receptor antibody, thyroid scintigraphy and ultrasound. To this day, four cases of new-onset GD following SARS-CoV-2 vaccine were reported in patients with no previous history of thyroid disease. Two cases of recurrence of GD following SARS-CoV-2 vaccine were also reported. Although the underlying mechanisms of vaccine-induced autoimmunity remain to be clarified, there is a rationale for the association between SARS-CoV-2 vaccination and the development of Th1-mediated diseases, at least in predisposed individuals. The BNT162b2 vaccine could be a trigger for GD in some patients. However, the benefit/risk ratio remains by far in favour of SARS-CoV-2 vaccination considering the potentially higher risk of severe infection in these patients.

Symptomatic Bradycardia Manifesting as Acute Hypothyroidism Following COVID-19 Infection: A Case Report

The role of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and associated autoimmune phenomenon behind pathology development has been a scientific mystery since the onset of the pandemic in 2020. Early on, scientific studies showed coronavirus disease 2019 (COVID-19) being linked to many pathological consequences including blood clots, neurocognitive dysfunction, and cardiomyopathy. We present a case of acute hypothyroidism in an 88-year-old female with no previous history of thyroid dysfunction or disease. The eventual workup revealed a thyroid-stimulating hormone (TSH) of greater than 100,000 milli-international units per liter (mlU/L) and a thyroxine (free T4) level of less than 0.10 nanograms per deciliter (ng/dl). At the time of presentation, she was found to have a positive COVID-19 test despite being vaccinated. She was started on a levothyroxine injection, which led to eventual symptom resolution. Our aim of this case report is to highlight the possibility of her acute hypothyroidism being triggered by the onset of COVID-19.

The Old and the New in Subacute Thyroiditis: An Integrative Review

Subacute thyroiditis (SAT) is the most common cause of neck pain and thyrotoxicosis. Although this disease was recognized already by the end of the 18th century, new concepts regarding pathogenesis have emerged in recent years. Moreover, in the last two years, literature on SAT has increased significantly due to articles describing the possible connection with coronavirus disease 2019 (COVID-19). This integrative review depicts old and new concepts of this disease, proposing a detailed overview of pathogenesis, a practical approach to diagnosis and treatment, and a thorough description of the latest discoveries regarding the association of SAT with COVID-19.

Serum Concentrations of Thyroid-Stimulating Hormone, Triiodothyronine, and Thyroxine in Outpatients Infected with SARS-CoV2 in Khuzestan Province, Iran: A Disease Clinical Course Approach

Background and Objectives: The virus SARS-CoV2, which causes COVID-19, affects the endocrine system. This study investigated serum concentrations of the thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4) in 53 outpatients infected with SARS-CoV2 and 53 non-infected matched participants in Khuzestan Province, Iran. We also examined the possible association of clinical symptoms progression and disease severity with serum concentrations of TSH, T3, and T4. Materials and Methods: A checklist was applied to collect demographic and clinical data. Blood samples were taken for biochemical analysis of serum concentrations of TSH, T3, and T4. Clinical symptoms of the infected outpatients were monitored weekly for 28 days. Results: Our results indicated that, as the severity of the disease increased, the respiratory and pulse rates raised significantly. Additionally, disease severity was significantly different between genders. Specifically, 79.5% of the asymptomatic/mild, and 38.5% of moderate outpatients were men. We also found significantly lower serum T3 but higher T4 in infected outpatients, compared with controls. However, serum TSH did not significantly differ between the two groups. The generalized estimating equation (GEE) analysis revealed no relationship between clinical symptoms progression and disease severity with serum concentrations of TSH, T3, and T4 in our study population. Additionally, GEE analysis showed that the odds ratio of neurological symptoms among women was 2.5 times that of men, the odds ratio of neurological symptoms in illiterates was 10 times higher than that of those without a high-school diploma, and the chance of developing pulmonary symptoms in those without high-school diploma was about 21 times higher than illiterates. Conclusion: In conclusion, this study showed that infected outpatients had significantly lower serum T3 but higher T4 than non-infected participants. There was no relation between symptom progression and disease severity with serum concentrations of TSH, T3, and T4, but educational status and sex significantly affected the chance of neurological and pulmonary symptoms occurring over 28 days. Our results may be used to develop potential therapies to treat COVID-19 disease.

COVID-19 AND THE THYROID FUNCTION IN PATIENTS WITH HCV- ASSOCIATED HEPATOCELLULAR CARCINOMA

Context

COVID-19 is more than a respiratory infection, with deep implications regarding multiple systems and organs. Thyroid damage is frequent in COVID-19 and may overlap previous HCV or HCC associated diseases.

Objective

The objective of this study is to determine the effects of COVID-19 in patients with HCV associated HCC and thyroid comorbidities.

Design

We performed a retrospective study of the thyroid function tests and autoantibodies in patients with HCV-associated HCC prior and during COVID-19.

Subjects and Methods

We included 52 consecutive patients with HCV-associated HCC and documented thyroid disease, diagnosed with COVID -19 between April and October 2020. Serum values of thyroid-stimulating hormone, free T3, free T4, anti-thyroglobulin antibodies and anti-thyroid peroxydase antibodies were determined and compared to baseline levels.

Results

At baseline, 44 patients had positive antithyroid antibodies, 6 had hypothyroidism in substitution and 2 had hyperthyroidism under treatment. During COVID-19 we found an increase in serum values of antithyroid antibodies, and decreased levels of TSH, freeT3 and freeT4 levels. Specific therapies were discontinued in one patient with hyperthyroidism and 3 patients with hypothyroidism.

Conclusion

There is a significant impact of COVID-19 on the thyroid homeostasis; a long-term prognostic value for patients with HCC infected with COVID-19 required further extensive research.

Further understanding of thyroid function in pregnant women

INTRODUCTION

Normal thyroid status throughout pregnancy is important for both maternal and fetal health. Despite the bulk of contemporary research honing on thyroid function in gestation and the relevant disorders, there are still gaps in our current knowledge about the etiology and treatment of thyroid diseases in pregnant women.

AREAS COVERED

This article analyzes the adaptation of the thyroid gland to gestational physiological changes and attempts to explain the effect of several factors on thyroid function in pregnancy. It also stresses proper utilization and interpretation of thyroid tests during pregnancy and underlines the significance of proper screening and treatment of pregnant women aiming at favorable health outcomes.

EXPERT OPINION

Appropriate strategies for diagnosing and treating thyroid disease in pregnancy are important. Laboratory thyroid testing plays a leading role, but test results should be interpreted with caution. Given the possible serious maternal and fetal/neonatal complications of thyroid disease in pregnancy, we recommend universal screening with TSH measurements of all pregnant women. Additional assessment with determination of the levels of free thyroid hormones and thyroid antibodies may be necessary under certain conditions. The economic burden of such interventions should be considered.

SARS-CoV-2 and Subacute Thyroiditis: A Case Report and Literature Review

Introduction

Subacute thyroiditis (SAT) is an inflammatory disorder of the thyroid gland, usually triggered by a recent viral or bacterial infection of upper respiratory tracts. The disease is characterized by neck pain radiating to the ears and thyroid gland tenderness. In most cases, it is associated with a transient episode of hyperthyroidism, which is followed by euthyroidism. However, sometimes, it manifests itself with hypothyroidism. Case Presentation. The present report described a case of SAT who was a 55-year-old man presenting to an endocrine clinic with tachycardia, tremor, and neck pain radiating to the jaw and ears. His thyroid function test revealed thyrotoxicosis, and thyroid ultrasound findings were consistent with SAT. The patient reported a history of COVID-19 about 15 days before presentation, which was confirmed by a positive PCR test for SARS-CoV-2.

Conclusions

It is of great importance for physicians to note that thyrotoxicosis in a patient with a recent history of COVID-19 can be due to SAT. Therefore, they should not begin antithyroid drugs without ordering proper investigations.

The Potential of Thyroid Hormone Therapy in Severe COVID-19: Rationale and Preliminary Evidence

Tissue hypoxia is one of the main pathophysiologic mechanisms in sepsis and particularly in COVID-19. Microvascular dysfunction, endothelialitis and alterations in red blood cell hemorheology are all implicated in severe COVID-19 hypoxia and multiorgan dysfunction. Tissue hypoxia results in tissue injury and remodeling with re-emergence of fetal programming via hypoxia-inducible factor-1α (HIF-1a)-dependent and -independent pathways. In this context, thyroid hormone (TH), a critical regulator of organ maturation, may be of relevance in preventing fetal-like hypoxia-induced remodeling in COVID-19 sepsis. Acute triiodothyronine (T3) treatment can prevent cardiac remodeling and improve recovery of function in clinical settings of hypoxic injury as acute myocardial infarction and by-pass cardiac surgery. Furthermore, T3 administration prevents tissue hypoxia in experimental sepsis. On the basis of this evidence, the use of T3 treatment was proposed for ICU (Intensive Care Unit) COVID-19 patients (Thy-Support, NCT04348513). The rationale for T3 therapy in severe COVID-19 and preliminary experimental and clinical evidence are discussed in this review.

Analysis of thyroid function in Japanese patients with coronavirus disease 2019

Thyroid dysfunction that is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is becoming increasingly recognized. However, only a few reports in Japan have addressed this issue to date. In this study, we sought to clarify whether infection with SARS-CoV-2 affected thyroid hormone levels and whether these hormones could be better predictors of prognosis in patients with coronavirus disease 2019 (COVID-19). Accordingly, we retrospectively examined 147 cases wherein thyroid hormones were measured at the time of admission among 848 Japanese patients with COVID-19 admitted to the Hyogo Prefectural Kakogawa Medical Center. All patients underwent thyroid function testing upon hospital admission. More than half (59.1%) of the patients were euthyroid. Twenty-four percent of patients had serum thyroid-stimulating hormone (TSH) levels lower than the reference range with normal serum free thyroxine (fT4) levels, and 3.4% of the patients had low TSH with high fT4 levels. Over 70% of the patients with moderate and severe COVID-19 had low serum free triiodothyronine (fT3) levels. Serum TSH and fT3 levels were inversely correlated with disease severity. The mortality rate in patients with low serum fT3 levels was significantly higher than that in those with normal serum fT3 levels.

Mast Cell Activation Syndrome in COVID-19 and Female Reproductive Function: Theoretical Background vs. Accumulating Clinical Evidence

Coronavirus disease 2019 (COVID-19), a pandemic disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, can affect almost all systems and organs of the human body, including those responsible for reproductive function in women. The multisystem inflammatory response in COVID-19 shows many analogies with mast cell activation syndrome (MCAS), and MCAS may be an important component in the course of COVID-19. Of note, the female sex hormones estradiol (E2) and progesterone (P4) significantly influence mast cell (MC) behavior. This review presents the importance of MCs and the mediators from their granules in the female reproductive system, including pregnancy, and discusses the mechanism of potential disorders related to MCAS. Then, the available data on COVID-19 in the context of hormonal disorders, the course of endometriosis, female fertility, and the course of pregnancy were compiled to verify intuitively predicted threats. Surprisingly, although COVID-19 hyperinflammation and post-COVID-19 illness may be rooted in MCAS, the available clinical data do not provide grounds for treating this mechanism as significantly increasing the risk of abnormal female reproductive function, including pregnancy. Further studies in the context of post COVID-19 condition (long COVID), where inflammation and a procoagulative state resemble many aspects of MCAS, are needed.

Thyroid Dysfunction and COVID-19: The Emerging Role of Selenium in This Intermingled Relationship

COVID-19 represents a worldwide public health emergency, and, beyond the respiratory symptoms characterizing the classic viral disease, growing evidence has highlighted a possible reciprocal relationship between SARS-CoV-2 infection and thyroid dysfunction. The updated data discussed in this review suggests a role of SARS-CoV-2 infection on the thyroid gland, with multiple thyroid pictures described. Conversely, no conclusion can be drawn on the association between pre-existing thyroid disease and increased risk of SARS-CoV-2 infection. In this scenario, selenium (Se), an essential trace element critical for thyroid function and known as an effective agent against viral infections, is emerging as a potential novel therapeutic option for the treatment of COVID-19. Large multicentre cohort studies are required to elucidate the mechanisms underlying thyroid dysfunction during or following recovery from COVID-19, including Se status. Meanwhile, clinical trials should be performed to evaluate whether adequate intake of Se can help address COVID-19 in Se-deficient patients, also avoiding thyroid complications that can contribute to worsening outcomes during infection.

SARS-CoV-2 vaccine-associated subacute thyroiditis: insights from a systematic review

PURPOSE

To perform a systematic review on published cases of subacute thyroiditis (SAT) secondary to SARS-CoV-2 vaccination, to highlight main features and increase the awareness of this condition.

METHODS

Original reports of SAT developed after SARS-CoV-2 vaccination (mRNA, viral vector, or inactivated virus vaccines) were retrieved from a search of electronic databases. Individual patient data on demographics, medical history, type of vaccine, workup and therapies were collected. Wilcoxon rank-sum, Kruskal-Wallis and chi-squared tests were employed for comparisons.

RESULTS

30 articles including 48 reports were retrieved, 3 additional cases evaluated by the Authors were described and included for analysis. Of the 51 patients, 38 (74.5%) were women, median age was 39.5 years (IQR 34-47). Patients developed SAT after a median of 10 days (IQR 4-14) after the vaccine shot. Baseline thyroid exams revealed thyrotoxicosis in 88.2% of patients, decreasing at 31.6% at follow-up. Corticosteroids were used in 56.4% of treated patients. Patients undergoing non-mRNA vaccines were most frequently Asian (p = 0.019) and reported more frequently weight loss (p = 0.021). All patients with a previous diagnosis of thyroid disease belonged to the mRNA vaccine group.

CONCLUSION

SARS-CoV-2 vaccine-associated SAT is a novel entity that should be acknowledged by physicians. Previous history of thyroid disease may predispose to develop SAT after mRNA vaccines, but further studies and larger cohorts are needed to verify this suggestion. SARS-CoV-2 vaccine-associated SAT is usually of mild/moderate severity and could be easily treated in most cases, thus it should not raise any concern regarding the need to be vaccinated.

COVID-19 and thyroid disease: An infodemiological pilot study

BACKGROUND

Google Trends searches for symptoms and/or diseases may reflect actual disease epidemiology. Recently, Google Trends searches for coronavirus disease 2019 (COVID-19)-associated terms have been linked to the epidemiology of COVID-19. Some studies have linked COVID-19 with thyroid disease.

AIM

To assess COVID-19 cases per se vs COVID-19-associated Google Trends searches and thyroid-associated Google Trends searches.

METHODS

We collected data on worldwide weekly Google Trends searches regarding “COVID-19”, “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)”, “coronavirus”, “smell”, “taste”, “cough”, “thyroid”, “thyroiditis”, and “subacute thyroiditis” for 92 wk and worldwide weekly COVID-19 cases' statistics in the same time period. The study period was split in half (approximately corresponding to the preponderance of different SARS-COV-2 virus variants) and in each time period we performed cross-correlation analysis and mediation analysis.

RESULTS

Significant positive cross-correlation function values were noted in both time periods. More in detail, COVID-19 cases per se were found to be associated with no lag with Google Trends searches for COVID-19 symptoms in the first time period and in the second time period to lead searches for symptoms, COVID-19 terms, and thyroid terms. COVID-19 cases per se were associated with thyroid-related searches in both time periods. In the second time period, the effect of “COVID-19” searches on “thyroid’ searches was significantly mediated by COVID-19 cases (P = 0.048).

CONCLUSION

Searches for a non-specific symptom or COVID-19 search terms mostly lead Google Trends thyroid-related searches, in the second time period. This time frame/sequence particularly in the second time period (noted by the preponderance of the SARS-COV-2 delta variant) lends some credence to associations of COVID-19 cases per se with (apparent) thyroid disease (via searches for them).

Thyrotoxicosis following SARS-COV-2 vaccination: a case series and discussion

AIM

To describe a case series of thyrotoxicosis likely triggered by SARS-CoV-2 vaccination and to warn physicians about this potential correlation. To report clinical, laboratory and imaging findings and provide further information that goes in line with the underlying mechanisms.

METHODS

Single-center case series based on all the information collected in the hospital medical records, as well as the temporal sequence between the onset of symptoms and COVID-19 vaccination.

RESULTS

We report 8 cases with thyrotoxicosis after SARS-CoV-2 vaccination. 4 cases of Graves' disease (GD), 2 cases of subacute painful thyroiditis (SAT), 1 case of concurrent GD and SAT and 1 case of atypical subacute thyroiditis. Five patients received BNT162b2 mRNA vaccine, 3 patients 1273 mRNA vaccine. The onset of symptoms following vaccination ranged from 10 to 14 days in six of eight patients and from 7 to 8 weeks in two patients.

CONCLUSIONS

Several hypotheses have been proposed to explain the potential correlation between SARS-CoV-2 vaccination and thyrotoxicosis, including immune system hyper-stimulation, molecular mimicry and Autoimmune/Autoinflammatory Syndrome Induced by Adjuvants (ASIA). We should pay greater attention to thyroid disorders in patients receiving vaccine against SARS-CoV-2.

Thyroid Function Abnormalities in the Acute Phase of COVID-19: A Cross-Sectional Hospital-Based Study From North India

Introduction Viral illnesses like mumps, cytomegalovirus (CMV), and Cocksakievirus have been shown to affect the endocrine system, specifically the thyroid as a product of their systemic inflammatory process. The thyroid gland, having high levels of angiotensin-converting enzyme 2 (ACE2) is also predisposed to dysfunction due to coronavirus disease 2019 (COVID-19). Methodology A cross-sectional study was conducted using retrospective data of thyroid function tests in patients with COVID-19. Results The majority of patients with COVID-19 had normal thyroid function while low serum T3, seen in 47.3% of patients with severe disease, stood out as the most common thyroid abnormality in the acute phase of the disease. The disease severity was seen to correlate with the extent of thyroid function abnormalities, with severely diseased patients having lower T3 values and normal to low thyroid-stimulating hormone (TSH) values. Furthermore, a significant negative correlation was seen between TSH and the bio-inflammatory marker, C-reactive protein (CRP). Conclusion The acute phase of COVID-19 affects thyroid function in direct correlation with the severity of the disease.

The prognostic values of thyroid disorders in predicting COVID-19 composite poor outcomes: A systematic review and meta-analysis

BACKGROUND AND AIMS

In this meta-analysis, we aimed to evaluate the prognostic properties of thyroid disorder during admission on poor prognosis and factors that may influence the relationship in patients with COVID-19.

METHODS

A systematic literature search of PubMed, EBSCO, and CENTRAL was conducted from inception to August 27, 2021. The main exposure was unspecified and specified thyroid disorders-hypothyroidism or hypothyroidism. The outcome of interest was the COVID-19 composite poor outcome that comprises of severity, mortality, ICU admission, and hospitalization.

RESULTS

There were 24,734 patients from 20 studies. Meta-analysis showed that thyroid disorder was associated with composite poor outcome (OR 2.87 (95% CI 2.04-4.04), p < 0.001; I² = 62.4%, p < 0.001). Meta regression showed that age (p = 0.047) and hypertension (p = 0.01), but not gender (p = 0.15), DM (p = 0.10), CAD/CVD (p = 0.38), obesity (p = 0.84), and COPD (p = 0.07) affected the association. Subgroup analysis showed that thyroid disorder increased risk of severe COVID-19 (OR 5.13 (95% CI 3.22-8.17), p < 0.05; I² = 0%, p = 0.70) and mortality (OR 2.78 (95%CI 1.31-5.90), p < 0.05; I² = 80%, p < 0.01). Pooled diagnostic analysis of thyroid disorder yielded a sensitivity of 0.22 (0.13-0.35), specificity of 0.92 (0.87-0.95), and AUC of 0.72. The probability of poor outcome was 38% in patients with thyroid disorder and 15% in patients without thyroid abnormality.

CONCLUSION

On-admission thyroid disorder was associated with poor prognosis in COVID-19 patients.

Basic mechanisms of SARS-CoV-2 infection. What endocrine systems could be implicated?

Although SARS-CoV-2 viral attacks starts by the interaction of spike protein (S Protein) to ACE2 receptor located at the cell surface of respiratory tract and digestive system cells, different endocrine targets, endocrine organs and metabolic conditions are of fundamental relevance for understanding disease progression and special outcomes, in particular those of fatal consequences for the patient. During pandemic, moreover, a specific phenotype of COVID-19 metabolic patient has been described, characterized by being at particular risk of worse outcomes. In the present paper we describe the mechanism of viral interaction with endocrine organs, emphasizing the specific endocrine molecules of particular relevance explaining COVID-19 disease evolution and outcomes.