Subacute, silent, and postpartum thyroiditis

Subacute thyroiditis in pregnancy: a narrative review

Thyroid dysfunction can adversely affect pregnancy outcomes. Apart from gestational thyrotoxicosis, thyroid dysfunction during pregnancy shares similar etiologies with the non-gravid state. Graves' disease is the most common cause of spontaneous hyperthyroidism in pregnancy, followed by thyroid autonomy. Although subacute thyroiditis is a less common cause of thyrotoxicosis in pregnancy, its associated pain, systemic symptoms, and thyroid dysfunction can present diagnostic and therapeutic challenges. In its painful form, subacute thyroiditis may lead to severe disability, with systemic glucocorticoids being the best effective treatment option. When painless, the condition often comes to medical attention due to thyroid dysfunction. During the thyrotoxic phase, subacute thyroiditis should be differentiated from gestational thyrotoxicosis, Graves' disease, and thyroid autonomy. Additionally, the transient hypothyroid phase may be misdiagnosed as permanent hypothyroidism, such as in Hashimoto's thyroiditis. Once properly diagnosed, management is symptomatic and focused on correcting the predominant abnormality. In this review, we summarize the current reported cases of subacute thyroiditis in pregnancy and discuss the challenges in diagnosis and management. Clinical trial number Not applicable.

Coexistence of giant cell arteritis and subacute thyroiditis: A case report and literature review

Giant cell arteritis and subacute thyroiditis are often regarded as clinically distinct diseases with differing pathogenesis. We report a rare case of coexisting giant cell arteritis and subacute thyroiditis that were both successfully managed using glucocorticoid therapy. Ultrasound plays a vital role in the diagnosis and treatment of these diseases. A review of the literature revealed that cases of giant cell arteritis complicated by subacute thyroiditis are very rare, and their pathogenesis and association are still unclear. We summarized the clinical features of giant cell arteritis complicated with subacute thyroiditis and found that none of the patients had symptoms associated with polymyalgia rheumatica. Subacute thyroiditis could be misdiagnosed as giant cell arteritis, and ultrasound is a useful tool for distinguishing the two diseases. Glucocorticoids are effective in the active period in patients with giant cell arteritis complicated with subacute thyroiditis. This case report would encourage clinicians to pay more attention to this phenomenon.

Potassium Iodide Use and Patient Outcomes for Thyroid Storm: An Observational Study

CONTEXT

Iodine, combined with antithyroid drugs, is recommended as an initial pharmacologic treatment for thyroid storm according to some clinical guidelines. However, the clinical efficacy of iodine in managing thyroid storm remains unexplored.

OBJECTIVE

This study aimed to determine whether early potassium iodide (KI) use is associated with mortality in patients hospitalized for thyroid storm.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we identified patients hospitalized with thyroid storm between July 2010 and March 2022. We compared in-hospital mortality, length of stay, and total hospitalization costs between patients who received KI within 2 days of admission (KI group) vs those who did not (non-KI group). Prespecified subgroup analyses were performed based on the presence of the diagnosis of Graves' disease.

RESULTS

Among 3188 eligible patients, 2350 received KI within 2 days of admission. The crude in-hospital mortality was 6.1% (143/2350) in the KI group and 7.8% (65/838) in the non-KI group. After adjusting for potential confounders, KI use was not significantly associated with in-hospital mortality (odds ratio [OR] for KI use, 0.91; 95% CI, 0.62-1.34). In patients with the diagnosis of Graves' disease, in-hospital mortality was lower in the KI group than in the non-KI group (OR, 0.46; 95% CI, 0.25-0.88). No significant difference in in-hospital mortality was observed in patients without the diagnosis of Graves' disease (OR, 1.11; 95% CI, 0.67-1.85). Length of stay was shorter (subdistribution hazard ratio, 1.15; 95% CI, 1.05-1.27), and total hospitalization costs were lower (OR, 0.92; 95% CI, 0.85-1.00) in the KI group compared with the non-KI group.

CONCLUSION

Our findings suggest that KI may reduce in-hospital mortality among patients hospitalized for thyroid storm with Graves' disease.

Causal association of epigenetic age acceleration and risk of subacute thyroiditis: a bidirectional Mendelian randomization study

BACKGROUND

Epigenetic age accelerations (EAAs) are a promising new avenue of research, yet their investigation in subacute thyroiditis (SAT) remains scarce. Our study endeavors to fill this void by exploring the potential causal association between EAAs and SAT.

METHODS

Our study utilized publicly available genome-wide association study (GWAS) data of European ancestry to conduct a bidirectional Mendelian randomization (MR) study. Five MR methods were employed to measure causal association between EAAs and SAT multiple analyses were utilized to perform quality control.

RESULTS

Our study evaluated causal association between SAT and four EAAs, included GrimAge acceleration (GrimAA), Hannum age acceleration (HannumAA), PhenoAge acceleration (PhenoAA), intrinsic epigenetic age acceleration (IEAA). Results showed that there is a significant causal association between PhenoAA and SAT (OR 1.109, 95% CI 1.000-1.228, p = 0.049, by IVW method). On the contrary, SAT was associated with IEAA (OR 0.933, 95% CI 0.884-0.984, p = 0.011, by IVW method; OR 0.938, 95% CI 0.881-0.998, p = 0.043, by weighted median method). Leave-one-out sensitivity analysis, heterogeneity test, pleiotropy test, and MR-PRESSO analysis provide good quality control.

CONCLUSION

The bidirectional MR analysis concluded that an increase in PhenoAA was correlated with a higher risk of SAT, indicating a potential causal relationship between PhenoAA and risk of SAT. Conversely, SAT was found to be closely associated with IEAA, suggesting that SAT may accelerate the aging process. Slowing down biological aging has emerged as a new research direction in curbing SAT.

Clinical use of thyroglobulin: not only thyroid cancer

Thyroglobulin (TG) is a dimeric glycoprotein produced exclusively by mature thyroid tissue and stored within the follicular lumen. It is essential for the organification of iodine and the production of thyroid hormones. The concentration of TG in the bloodstream varies between individuals and depends on factors such as thyroid mass, stimulation of the gland by thyrotropin or autoantibodies, and tissue destruction. TG is essential to monitor patients with differentiated thyroid cancer; however, its use is not limited only to this clinical entity. Measurement of circulating TG can provide better insight into numerous clinical scenarios, such as destructive thyroiditis, presence of ectopic thyroid tissue, thyroid trauma, factitious thyrotoxicosis, or iodine nutrition. Lately, TG has found its new clinical use in immune checkpoint-related thyroid dysfunction. TG measurement should be performed carefully in patients with antithyroglobulin antibodies due to possible laboratory interferences. In this review, we offer a summary of current knowledge about the clinical use of TG and the implications it brings to daily practice.

Risk of Incident Thyroid Dysfunction in the Post-Acute Phase of COVID-19: A Population-Based Cohort Study in Hong Kong

OBJECTIVE

The evidence of thyroid dysfunction in the post-acute phase of SARS-CoV-2 infection is limited. This study aimed to evaluate the risk of incident thyroid dysfunction in the post-acute phase of COVID-19.

METHODS

This retrospective, propensity-score matched, population-based study included COVID-19 patients and non-COVID-19 individuals between January 2020 and March 2022, identified from the electronic medical records of the Hong Kong Hospital Authority. The cohort was followed up until the occurrence of outcomes, death, or 31 January 2023, whichever came first. Patients with COVID-19 were 1:1 matched to controls based on various variables. The primary outcome was a composite of thyroid dysfunction (hyperthyroidism, hypothyroidism, initiation of antithyroid drug or levothyroxine, and thyroiditis). Cox regression was employed to evaluate the risk of incident thyroid dysfunction during the post-acute phase.

RESULTS

A total of 84 034 COVID-19 survivors and 84 034 matched controls were identified. Upon a median follow-up of 303 days, there was no significant increase in the risk of diagnosed thyroid dysfunction in the post-acute phase of COVID-19 (hazard ratio [HR] 1.058, 95% confidence interval 0.979-1.144, P = .154). Regarding the secondary outcomes, patients with COVID-19 did not have increased risk of hyperthyroidism (HR 1.061, P = .345), hypothyroidism (HR 1.062, P = .255), initiation of antithyroid drug (HR 1.302, P = .070), initiation of levothyroxine (HR 1.086, P = .426), or thyroiditis (P = .252). Subgroup and sensitivity analyses were largely consistent with the main analyses.

CONCLUSION

Our population-based cohort study provided important reassuring data that COVID-19 was unlikely to be associated with persistent effects on thyroid function.

Comparison of treatment outcome between glucocorticoids and non-steroidal anti-inflammatory drugs in subacute thyroiditis patients-a systematic review and meta-analysis

Importance

Subacute thyroiditis (SAT) is a self-limiting and inflammatory thyroid disease. Although SAT usually improves on its own within weeks, it needs treatment when patients have pain, fever, and symptoms of thyrotoxicosis. Therapeutic drugs mainly include non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids. Currently, there is no systematic review or meta-analysis of the comparison of outcomes between NSAIDs and glucocorticoids for the treatment of SAT.

Objectives

To conduct a systematic review and meta-analysis on the outcomes in subacute thyroiditis patients treated with glucocorticoids or NSAIDs.

Data sources

Using the four electronic databases, including PubMed, Embase, Cochrane Library, Wanfang database and Web of Science. All publications until 21 June 2023 were searched. The reference lists of all selected articles were independently screened to identify additional studies left out in the initial search.

Study selection

The literature comparing outcomes between glucocorticoids and non-steroidal anti-inflammatory drugs for patients with subacute thyroiditis will be included.

Data extraction and synthesis

Two independent investigators (Anqi Yuan and Jialu Wu) extracted the data following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (PRISMA) and then evaluated the quality of the eligible studies with the Newcastle-Ottawa Scale. Fixed-effects models for the meta-analyses were applied. Heterogeneity was assessed with the chi-squared (x²) test (Cochran's Q) and inconsistency index (I²). The robustness of the results was tested with the sensitivity analyses. The bias of publication was assessed with the Harbord test.

Main outcomes and measures

The incidence of permanent hypothyroidism in SAT patients treated with corticosteroids or NSAIDs.

Results

Our study included a total of ten comparative cohort studies with 1337 participants. We found that the incidence of developing permanent hypothyroidism in the SAT patients who received glucocorticoids treatment was significantly lower than those who received NSAIDs treatment. (OR, 0.56; 95% CI, 0.36-0.88; P = 0.01). The risk of permanent hypothyroidism in patients who received prednisone at an average initial dose < 40 mg/d was significantly lower than that in patients who received NSAIDs (OR, 0.37; 95% CI, 0.14-0.94; P = 0.04). There was no significant difference in the occurrence of permanent hypothyroidism between SAT patients who received an average initial dose ≥ 40 mg/d of prednisone and those who received only NSAIDs (OR, 0.7; 95% CI, 0.14-3.53; P = 0.67). In addition, the recurrence rate was observably higher in those receiving glucocorticoids than in those receiving NSAIDs (OR, 1.98; 95% CI, 1.12-3.5; p = 0.02). The recurrence rate was significantly higher in patients with an average initial prednisone dose of < 40 mg/d than in the NSAIDs group. There was no significant difference in the recurrence rate between patients in the mean initial prednisone dose ≥ 40 mg/d group and those in the NSAIDs group.

Conclusions and relevance

In this meta-analysis, we compared the treatment outcomes of SAT patients between glucocorticoids and NSAIDs. Our results indicated that glucocorticoid treatment was associated with a lower incidence of permanent hypothyroidism than NSAID treatment. Patients treated with NSAIDs might have a lower recurrence rate. This finding might help to understand the outcome of the disease when choosing different drugs and help physicians to make appropriate decisions.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023427332.

Acupuncture treatment for Hashimoto's thyroiditis: An exploratory randomized controlled trial

Background

Hashimoto's thyroiditis (HT) has a high incidence rate and unresolved clinical symptoms. Although Hand Yangming Meridian Penetrating Acupuncture has been used to treat thyroid diseases in China, there is no randomized controlled trial (RCT) on HT.

Methods

This exploratory RCT aims to preliminarily evaluate the efficacy, safety, and feasibility of Hand Yangming Meridian Penetrating Acupuncture in the treatment of HT. Included subjects were randomly assigned to the acupuncture group and the waiting treatment group at a ratio of 1:1. Subjects in the acupuncture group received 16 weeks of acupuncture treatment, followed by a 16-week follow-up observation phase. Subjects in the waiting group received thyroxine supplementation for 16 weeks, followed by 16 weeks of compensation treatment. Serum thyroid peroxidase antibody (TPOab) and thyroglobulin antibody (TGab) levels were the main indicators, and Thyroid-Related Patient-Reported Outcome short form (ThyPRO-39), MOS Item Short Form Health Survey (SF-36), and Hospital Anxiety and Depression Scale (HADS) scores were also recorded.

Results

In total, 58 subjects were included. After 16 weeks of treatment, there was no statistical difference in the changes in TPOab levels between the two groups, but the TGab level in the acupuncture group was significantly lower than in the waiting group (difference: -141.97 [95 % CI: -222.4 to -61.5], P = 0.011). Moreover, the total ThyPRO-39 and SF-36 scores were statistically different between the two groups (PThyPRO-39 < 0.001, PSF-36 = 0.005). There was no statistical difference in HADS between the two groups.

Conclusions

Hand Yangming Meridian Penetrating Acupuncture may be safe and feasible for HT hypothyroidism to improve symptoms and reduce TGab levels.

Trial registration number

This trial was registered at Acupuncture-Moxibustion Clinical Trial Registry: AMCTR-IOR-19000308 (ChiCTR1900026830, https://www.chictr.org.cn/searchprojEN.html).

Clinical Aspects in Subacute Thyroiditis: A Real-Life Study on 226 Cases in Greece Amid the COVID-19 Pandemic

PURPOSE

This study aimed to evaluate various therapeutic approaches, identify potential predictive factors for the recurrence and development of hypothyroidism, and examine specific clinical and laboratory characteristics of patients with subacute thyroiditis (SAT) due to SARS-CoV-2 infection.

METHODS

We retrospectively analyzed the medical records of 226 patients with confirmed SAT diagnosed from January 2020 to November 2022.

RESULTS

The mean age was 48.01 ± 0.75 years, and the F/M ratio was 2.3/1. At the end of the follow-up period, 69 patients (32.1%) had developed hypothyroidism. Treatment duration was significantly shorter with nonsteroidal anti-inflammatory drugs (NSAIDs) (17.40 ± 2.56 days), while time-to-symptom relief was shorter with glucocorticoids (CGs). Recurrence was observed only in those treated with corticosteroid preparations (14.1%). C-reactive protein levels at treatment discontinuation were higher in patients who experienced SAT recurrence, while the coexistence of Hashimoto's thyroiditis was a significant predictive factor for the development of hypothyroidism. The TSH value at the time of treatment withdrawal >4.12 μIU/mL showed optimal sensitivity and specificity for the prediction of permanent hypothyroidism. Regarding COVID-19, 34 patients (15%) experienced related SAT, with similar clinical manifestations of the disease but a higher BMI and shorter time-to-symptom relief.

CONCLUSION

In conclusion, GCs administration alleviated acute symptoms earlier during the onset of SAT, whereas NSAIDs had a shorter treatment duration, and both regimens could not prevent the development of delayed hypothyroidism. The clinical characteristics of SAT due to COVID-19 infections were similar to those of typical SAT disease.

COVID-19 vaccination and thyroiditis

At the end of 2019, the world began to fight the coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus-2. Many vaccines have quickly been developed to control the epidemic, and with the widespread use of vaccines globally, several vaccine-related adverse events have been reported. This review mainly focused on COVID-19 vaccination-associated thyroiditis and summarized the current evidence regarding vaccine-induced subacute thyroiditis, silent thyroiditis, Graves' disease, and Graves' orbitopathy. The main clinical characteristics of each specific disease were outlined, and possible pathophysiological mechanisms were discussed. Finally, areas lacking evidence were specified, and a research agenda was proposed.

COVID-19: Findings in nuclear medicine from head to toe

COVID-19 is a multisystemic disease, and hence its potential manifestations on nuclear medicine imaging can extend beyond the lung. Therefore, it is important for the nuclear medicine physician to recognize these manifestations in the clinic. While FDG-PET/CT is not indicated routinely in COVID-19 evaluation, its unique capability to provide a functional and anatomical assessment of the entire body means that it can be a powerful tool to monitor acute, subacute, and long-term effects of COVID-19. Single-photon scintigraphy is routinely used to assess conditions such as pulmonary embolism, cardiac ischemia, and thyroiditis, and COVID-19 may present in these studies. The most common nuclear imaging finding of COVID-19 vaccination to date is hypermetabolic axillary lymphadenopathy. This may pose important diagnostic and management dilemmas in oncologic patients, particularly those with malignancies where the axilla constitutes a lymphatic drainage area. This article aims to summarize the relevant literature published since the beginning of the pandemic on the intersection between COVID-19 and nuclear medicine.

Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis

Hyperthyroidism is a common condition with a global prevalence of 0·2-1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT4], or high free tri-iodothyonine [FT3]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12-18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT4 concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5-10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12-18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (131I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.

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.

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.

The effects of circulating MIR22-3p and MIR16-1-3p levels in different stages of subacute thyroiditis

Subacute thyroiditis (SAT) is an inflammatory thyroid disease with a frequency is 5% among all thyroid diseases. miRNAs are endogenous, non-coding RNAs ranging in length from 19 to 25 nucleotides. They play an important role in the posttranscriptional regulation of gene expression. In this study, we aimed to investigate whether the expression levels of two circulating miRNAs, MIR22 and MIR16-1, can be used as a parameter in the diagnosis and follow-up of SAT disease. Fifty patients diagnosed with SAT and 41 healthy controls were included in this study. Expression levels of miRNAs were determined by real time-PCR method. Expression data of miRNAs were calculated by fold change (2^-ΔΔCt) method. The statistical significance of miRNA expression was evaluated by t-test. The expression levels of MIR22-3p and MIR16-1-3p were not found to be statistically different between SAT patients and controls and also between the patients in different stages (hyperthyroid, euthyroid, and hypothyroid) of the disease. According to correlation analyses, we observed a positive strong correlation between erythrocyte sedimentation rate (ESR) and the expression levels of MIR22-3p and MIR16-1-3p (r = 0.960, p = 0.000 and r = 0.865, p = 0.006, respectively), and a positive strong correlation between fT4 and the expression levels of MIR22-3p in SAT patients in euthyroid stage (r = 0.712, p = 0.047). In this study, we showed that the expression levels of MIR22-3p and MIR16-1-3p have correlation with clinical characteristics of SAT disease. Our results suggest that MIR22 and MIR16-1 may be effective in the pathogenesis of SAT.

Thyroid dysfunction following vaccination with COVID-19 vaccines: a basic review of the preliminary evidence

PURPOSE

The safety and efficacy of the several types of COVID-19 vaccines, including mRNA-based, viral vector-based, and inactivated vaccines, have been approved by WHO. The vaccines can confer protection against severe SARS-CoV-2 infection through induction of the anti-spike protein neutralizing antibodies. However, SARS-CoV-2 vaccines have been associated with very rare complications, such as thyroid disorders. This review was conducted to highlight main features of thyroid abnormalities following COVID-19 vaccination.

METHODS

A comprehensive search within electronic databases was performed to collect reports of thyroid disorders after vaccination with COVID-19 vaccines.

RESULTS

Among 83 reported cases including in this review, the most cases of thyroid abnormalities were observed after vaccination with mRNA-based vaccines (68.7%), followed by viral vector vaccines (15.7%) and 14.5% cases following inactivated vaccines. Subacute thyroiditis (SAT) was the most common COVID-19 vaccination-related thyroid disease, accounting for 60.2% of all cases, followed by Graves' disease (GD) with 25.3%. Moreover, some cases with focal painful thyroiditis (3.6%), silent thyroiditis (3.6%), concurrent GD and SAT (2.4%), thyroid eye disease (1.2%), overt hypothyroidism (1.2%), atypical subacute thyroiditis (1.2%), and painless thyroiditis with TPP (1.2%) were also reported. Overall, in 58.0% of SAT cases and in 61.9% of GD cases, the onset of the symptoms occurred following the first vaccine dose with a median of 10.0 days (ranged: 3-21 days) and 10.0 days (ranged: 1-60 days) after vaccination, respectively. Moreover, 40.0% of SAT patients and 38.1% of GD patients developed the symptoms after the second dose with a median of 10.5 days (ranged: 0.5-37 days) and 14.0 days (ranged: 2-35 days) after vaccination, respectively.

CONCLUSION

Fortunately, almost all cases with COVID-19 vaccination-associated thyroid dysfunctions had a favorable outcome following therapy. The benefits of COVID-19 vaccinations in terms of terminating the pandemic and/or reducing mortality rates can exceed any risk of infrequent complications such as a transient thyroid malfunction.

Endocrine and metabolic complications of COVID-19: lessons learned and future prospects

Coronavirus disease 2019 (COVID-19) is well known for its respiratory complications; however, it can also cause extrapulmonary manifestations, including cardiovascular, thrombotic, renal, gastrointestinal, neurologic, and endocrinological symptoms. Endocrinological complications of COVID-19 are rare but can considerably impact the outcome of the patients. Moreover, preexisting endocrinologic disorders can affect the severity of COVID-19. Thyroid, pancreas, adrenal, neuroendocrine, gonadal, and parathyroid glands are the main endocrinologic organs that can be targeted by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Endocrinological complications of COVID-19 are rare but can significantly deteriorate the patients' prognosis. Understanding the interaction between COVID-19 and the endocrine system can provide a potential treatment option to improve the outcome of COVID-19. In this article, we aim to review the short-term and long-term organ-based endocrinological complications of COVID-19, the pathophysiology, the influence of each complication on COVID-19 prognosis, and potential therapeutic interventions based on current published data. Moreover, current clinical trials of potential endocrinological interventions to develop therapeutic strategies for COVID-19 have been discussed.

Evaluation of the diagnostic features and clinical course of COVID-19 vaccine-associated subacute thyroiditis

OBJECTIVE

This study aimed to identify cases of coronavirus disease 2019 (COVID-19) vaccine-associated subacute thyroiditis (SAT) during the active vaccination period of the pandemic, analyze the characteristics of these cases, and compare them with cases of non-vaccine associated SAT diagnosed in the same period.

METHODS

A total of 55 patients diagnosed with SAT in our outpatient clinic between February and October, 2021, were included in this retrospective single-center study.

RESULTS

Of the study population, 16 (29.1%) were diagnosed with COVID-19 vaccine-associated SAT (10 with CoronaVac® and six with Pfizer-BioNTech® vaccine), with a median time to onset of symptoms after vaccination of 6.5 (range, 2-20) days. There was no statistically significant difference between the vaccine-associated (VA) and non-vaccine associated (NVA) groups in terms of age, gender, time to diagnosis, thyroid volumes, thyroid function tests, and acute phase reactants. Seven (43.8%) and 25 (64.1%) patients were treated with methylprednisolone in the VA group and NVA group, respectively (p = 0.16). Follow-up data of 45 patients (16/16 for VA and 29/39 for NVA) were available. The mean follow-up of these patients was 47.4 ± 19.4 days, and the follow-up periods of the VA group and NVA group were comparable (p = 0.24). There was no difference between the two groups in terms of the frequency of euthyroidism at the follow-up visit (12/16 vs.14/29, p = 0.08).

CONCLUSION

With the increase in COVID-19 vaccination rates during the current pandemic, VA SAT cases are seen more frequently. The present study demonstrated that these cases have similar diagnostic features and clinical course to that of classic forms of SAT. In addition, most patients with VA SAT had a mild clinical course that improved with non-steroidal anti-inflammatory drugs.

Subacute Thyroiditis Following SARS-CoV-2 Vaccines: Six Cases Report and Review of the Literature

Subacute thyroiditis (SAT) is an inflammatory disease of the thyroid that develops following viral upper respiratory tract infections. SARS-CoV-2 virus, the cause of COVID-19, binds to the Angiotensin-Converting Enzyme-2 (ACE2) molecule expressed on the target cell surface. Thyroid gland shows high levels of ACE2 expression. The cases of SARS-CoV-2-related subacute thyroiditis and Graves' disease have been reported. It has recently been noted that vaccines for SARS-CoV-2 also induce autoimmune and inflammatory reactions. We present six (4 male, 2 female) cases of SAT that developed after mRNA and inactivated SARS-CoV-2 vaccines. And we have reviewed the literature. SAT was seen in 5 patients after mRNA vaccine, in one after inactivated vaccine. Their clinic and laboratory findings suggested to SAT. They were treated with nonsteroid anti-inflamatory drugs and/or methylprednisolone.They recovered within few weeks. Out patients did not have permanent hypothyroidism after SAT. The history of SARS-CoV-2 vaccination should be questioned in patients with subacute thyroiditis in pandemic days.

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.

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.

Two cases of subacute thyroiditis after different types of SARS-CoV-2 vaccination

Although the development of subacute thyroiditis (SAT) following viral infections is well-documented, the actual mechanism has not been clearly elucidated. The occurrence of SAT after vaccination has been reported in several case series and possible mechanisms such as molecular mimicry due to the exposure to viral proteins and/or abnormal reactogenicity by adjuvants have been implicated. We describe two cases who developed SAT three days after the messenger RNA vaccine against COVID-19 (Pfizer-BioNTech®) and six days after the inactivated COVID-19 vaccine (CoronaVac®). SAT diagnosis of these patients was delayed for more than two weeks. When the current cases were evaluated together with 1 Pfizer-BioNTech® and 3 CoronaVac® related cases reported previously, the patients were female aged between 30-42, except for the male patient we presented, and the complaints of the patients initiated within the first 2-7 days. While two Pfizer-BioNTech® vaccine-related cases were severely symptomatic and thyrotoxic at presentation, there were cases with mild to moderate clinical manifestations in CoronaVac® vaccine-related group. Physicians should be aware of SAT that may occur within a few days following the COVID-19 vaccination.

Vaccine-Induced Subacute Thyroiditis (De Quervain's) after mRNA Vaccine against SARS-CoV-2: A Case Report and Systematic Review

De Quervain's thyroiditis, sometimes referred to as subacute thyroiditis (SAT), is the most common granulomatous disease of the thyroid, typically found after a viral infection in middle-aged women. The mRNA encoding for the angiotensin-converting enzyme-2 (ACE-2) receptor is expressed in follicular thyroid cells, making them a potential target for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Besides infection, SARS-CoV-2 vaccines have also been implicated in SAT pathogenesis. We present a case of a woman developing SAT following vaccination with Comirnaty by Pfizer Inc. (New-York, USA). We performed a systematic review of similar cases available in the literature to provide a better understanding of the topic. We searched the databases PubMed and Embase and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Patient records were then sorted according to the type of administered vaccine and a statistical analysis of the extracted data was performed. No statistically significant difference between mRNA vaccines and other vaccines in inducing SAT was found, nor was any found in terms of patient demographics, symptoms at presentation, initial, or follow-up blood tests. In our case report, we described the possible association between SARS-CoV-2 mRNA-based vaccine Comirnaty and SAT.

Endocrine system after 2 years of COVID-19 vaccines: A narrative review of the literature

PURPOSE

The purpose of this study was to describe the current knowledge on the potential endocrine adverse effects post-COVID-19 vaccines.

METHODS

A PubMed/MEDLINE, Web of Science, and Scopus research was performed. Case reports, case series, original studies, and reviews written in English and published online up to 31 July 2022 were selected and reviewed. The final reference list was defined based on the relevance of each paper to the scope of this review.

RESULTS

The available data showed that endocrine side effects are generally rare and with favorable outcome, being thyroid disorders the most common. Conversely, data on type 1 diabetes mellitus are rare; adrenal and pituitary events are even anecdotal. Finally, the available clinical studies suggest no impact on female reproductive system and on male and couple fertility.

CONCLUSION

Overall, these data show that, after 2 years of COVID-19 vaccines, the endocrine system is not heavily threatened.

Clinical Manifestation of Subacute Thyroiditis Triggered by SARS-CoV-2 Infection Can Be HLA-Dependent

In the last two years, we have been struggling with the pandemic of SARS-CoV-2, the virus causing COVID-19. Several cases of subacute thyroiditis (SAT) have already been described as directly related to SARS-CoV-2 infection. The clinical course of SAT induced by SARS-CoV-2 can be entirely different from the classic SAT course, and one of the most important differences is a very rapid SAT onset observed in some patients, especially a phenomenon of the simultaneous presence of both diseases. The aim of this report is to compare HLA profile and clinical course of SAT in four patients, in whom SAT was considered as triggered by COVID-19, with special attention paid to the differences between a patient with rare simultaneous presence of SAT and COVID-19, and patients with longer time lag between the diseases. The unusual phenomenon of simultaneous occurrence of COVID-19 and SAT induced by SARS-CoV-2 infection can be HLA-dependent and related to the presence of homozygosity at HLA-B*35. Additionally, the clinical course of SAT triggered by COVID-19 can be HLA-related in regard to the risk of recurrence, and to a variety of other aspects, including severity of thyrotoxicosis.

New aspects in the pathogenesis and management of subacute thyroiditis

Subacute thyroiditis (SAT) is a thyroid inflammatory disease, whose pathogenesis and determinants of the clinical course were unclear for many decades. The last few years have brought many clinically significant new data on the epidemiology, pathogenesis and management of SAT. Several human leukocyte antigen (HLA) alleles were demonstrated not only to increase the risk of SAT, but also to correlate with SAT clinical course and determine the risk of recurrence. The world-wide epidemic of the coronavirus disease 19 (COVID-19) has provided new observations that the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) can be a potent SAT-triggering factor, and that the clinical course of SAT in patients affected by COVID-19 is different from a typical one. Additionally, many new trends in the clinical course are emerging. In the last years, painless course of SAT is more and more often described, constituting a special challenge in patients hospitalized due to COVID-19. Despite an excellent availability of diagnostic methods, several difficulties in SAT differential diagnosis can be currently encountered and the proper diagnosis and treatment is frequently delayed. False positive diagnoses of SAT in patients with malignancies of poor prognosis constitute a life-threatening problem. Taking into account all the new aspects of SAT pathogenesis and of its clinical course, the new - modified - SAT diagnosis criteria have been proposed.

Successful Management of Subacute Thyroiditis Following SARS-CoV-2 Infection

Subacute thyroiditis (SAT) is a disorder of the thyroid gland and difficult to diagnose. It is probably triggered by a viral infection. Recently, several articles have reported SAT after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, reports describing SAT after SARS-CoV-2 in Japan are lacking. We herein report the first case of SAT after SARS-CoV-2 infection in Japan. After SARS-CoV-2 infection, some patients can develop not only pneumonia but also SAT. Thus, a careful follow-up is recommended for patients after SARS-CoV-2 infection. Furthermore, the effect of SARS-CoV-2 infection on thyroid dysfunction should not be ignored.

Two Important Issues in Subacute Thyroiditis Management: Delayed Diagnosis and Inappropriate Use of Antibiotics

BACKGROUND

Subacute thyroiditis (SAT) is a rare inflammatory disease of the thyroid gland. It has been noticed that patients with a diagnosis of SAT visit more other clinics and receive antibiotics unnecessarily. Therefore, the aim of this study was to reveal the degree of delay in the diagnosis of SAT, prediagnosis antibiotic use rates, and the awareness of clinics for the diagnosis of SAT.

METHODS

A total of 121 patients with SAT were enrolled in the study. A retrospective analysis was made of the history of patient symptoms during the diagnosis, which physicians they visited, antibiotic use, laboratory test results, and ultrasonographic findings.

RESULTS

The median age of the patients was 41 years. Neck pain radiating to the jaw/ear was seen in most patients (71.1%). The median time from symptom onset to a diagnosis of SAT was 23 days (range, 6-70 days). Antibiotics were erroneously prescribed to 71 patients (58.7%) before the diagnosis. The median time to diagnosis was 28 days in patients using antibiotics and 20 days in the group not using antibiotics (p < 0.001). Two or more physicians had been visited before SAT diagnosis by 89 (73.6%) patients, and more antibiotics were prescribed to these patients than the group who visited fewer physicians (p < 0.05). The frequency of prescribing antibiotics by physicians was 73.7% by emergency physicians, 53.1% by family doctors, 51.1% by ENT specialists, and 35.4% by internal medicine specialists.

CONCLUSION

The diagnosis of SAT is often delayed, and misdiagnosis leads to erroneous antibiotic overuse. Physicians should increase their awareness of the diagnosis of SAT in patients with neck pain.

Risk factors, Treatment and Outcomes of Subacute Thyroiditis Secondary to COVID-19: A Systematic Review

Background

COVID‐19 is known to cause an acute respiratory illness, although clinical manifestations outside of the respiratory tract may occur. Early reports have identified SARS‐CoV‐2 as a cause of subacute thyroiditis (SAT).

Methods

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. MEDLINE, Web of Science and PubMed databases were queried in February 2021 for studies from December 2019 to February 2021. MeSH search terms ‘COVID‐19’, ‘SARS‐CoV‐2’ and ‘coronavirus’ along with search terms ‘thyroiditis’, ‘thyrotoxicosis’ and ‘thyroid’ were used. Descriptive statistics for continuous variables and proportions for categorical variables were calculated.

Results

Fifteen publications reporting on 17 individual cases of COVID‐19‐induced SAT were identified. Age ranged from 18 to 69 years. The majority (14 of 17; 82%) of cases were female. The delay between onset of respiratory symptoms and diagnosis of SAT ranged from 5 to 49 days (mean, 26.5). Systemic inflammatory response syndrome related to viral infection was uncommonly reported at the time of SAT diagnosis. Thyroid ultrasonography frequently reported an enlarged hypoechoic thyroid with decreased vascularity and heterogenous echotexture. Elevated C‐reactive protein (CRP) was common at the time of SAT diagnosis, with results ranging from 4.5 to 176 mg/L (mean, 41 mg/L). Antithyroid antibodies were frequently negative. SAT‐specific treatment included corticosteroids for 12 of 17 (70.5%) patients. Most returned to normal thyroid status.

Conclusion

COVID‐19‐associated SAT may be difficult to identify in a timely manner due to potential absence of classic symptoms, as well as cross‐over of common clinical features between COVID‐19 and thyrotoxicosis.

COVID-19: A Potential Trigger for Thyroid Dysfunction

Subacute thyroiditis (SAT) is a self-limiting thyroid dysfunction of viral origin. Relatively little is known about its occurrence in SARS CoV-2 infected COVID-19 patients. Herein, we report a case of SAT in a 58-year-old patient that was apparently triggered by infection with SARS CoV-2. Clinical, laboratory and imaging features of the patient are presented. The patient was vitally stable with a slightly tender and warm thyroid gland, which was painful on swallowing. His free thyroxine (FT4) was elevated, thyroid stimulating hormone (TSH) was below normal and free triiodothyronine (FT3) was in the physiological range. Previous thyroid exam conducted as a part of routine annual physical checkup was normal. The patient was put on prednisolone and recovered completely within three weeks.

[Clinical practice guidelines for acute and chronic thyroiditis (excluding autoimmune thyroiditis)]

Острые и хронические заболевания щитовидной железы занимают второе место по выявляемости после сахарного диабета. Всемирная организация здравоохранения отмечает ежегодную тенденцию к увеличению числа заболеваний щитовидной железы. В настоящих клинических рекомендациях будут рассмотрены вопросы этиологии, клинического течения, диагностики и лечения острых и хронических (за исключением аутоиммунного) воспалительных заболеваний щитовидной железы.Клинические рекомендации — это основной рабочий инструмент практикующего врача, как специалиста, так и врача узкой практики. Лаконичность, структурированность сведений об определенной нозологии, методов ее диагностики и лечения, базирующихся на принципах доказательной медицины, позволяют в короткий срок дать тот или иной ответ на интересующий вопрос специалисту, добиваться максимальной эффективности и персонализации лечения.Клинические рекомендации составлены профессиональным сообществом узких специалистов, одобрены экспертным советом Министерства здравоохранения РФ. Представленные рекомендации содержат максимально полную информацию, которая требуется на этапе диагностики острых и хронических тиреоидитов, этапе выбора тактики ведения пациентов с тиреоидитом, а также на этапе лечения пациента.Рабочая группа представляет этот проект в профессиональном журнале, посвященном актуальным проблемам эндокринологии, с целью повышения качества оказываемой медицинской помощи, повышения эффективности лечения острых и хронических тиреоидитов путем ознакомления с полным тестом клинических рекомендаций по острым и хроническим тиреоидитам (исключая аутоиммунный тиреоидит) максимально возможного количества специалистов в области не только эндокринологии, но и медицины общей (семейной) практики.

Painful Subacute Thyroiditis is Commonly Misdiagnosed as Suspicious Thyroid Nodular Disease

Objective

To investigate and characterize the clinical and radiologic features of 10 patients with painful subacute thyroiditis with ultrasound findings considered suspicious for malignancy or for whom biopsy of a suspicious area was recommended by an attending radiologist.

Patients and Methods

Ten patients with painful subacute thyroiditis were seen from June 1, 2016, through January 1, 2019. All 10 patients presented to an endocrine or thyroid clinic with a neck ultrasound report stating findings suspicious for malignancy or nodular disease. Clinical, laboratory, radiographic, and pathologic data were (retrospectively collected and) reviewed.

Results

The mean ± SD patient age was 49.0±15.0 years at diagnosis; 8 patients were female. All the patients presented with a low or undetectable serum thyrotropin level. Six of 7 patients with available inflammatory markers had elevated levels. Thyrotropin receptor antibodies were absent in all 6 patients tested. On follow-up imaging, 8 patients had complete resolution or improvement of described findings, 1 was lost to follow-up, and 1 had an incidental nodule that was biopsied after the episode of thyroiditis and found to be papillary thyroid carcinoma.

Conclusion

Painful subacute thyroiditis demonstrates specific sonographic patterns that may be misdiagnosed as suspicious thyroid nodular disease. Recognition of the innocent and transient nature of these findings is important for the proper management and monitoring of these patients.

Risk Factors for Subacute Thyroiditis Recurrence: A Systematic Review and Meta-Analysis of Cohort Studies

BACKGROUND

Subacute thyroiditis (SAT) is a self-limited inflammatory thyroid disease with recurring episodes. However, the results regarding the recurrence rate and risk factors for SAT are inconsistent. This meta-analysis aimed to summarize the evidence of the recurrence rate and the risk factors for SAT.

METHODS

The present study involved the performance of a systematic literature search of all English studies published in PubMed, Embase, Web of Science, and The Cochrane Library from inception to August 20, 2021. Cohort studies that reported the SAT recurrence rate and risk factors for recurrence were included. Two independent investigators extracted relevant information. Fixed- and random-effects models were used to pool effect sizes based on study heterogeneity.

RESULTS

Eighteen cohort studies were identified. The pooled findings showed that the recurrence rate was 12.0% (95% CI: 8.2%, 17.1%). The risk of recurrence in the glucocorticoids group was higher than that in the NSAIDs group (RR = 1.84, 95% CI: 1.04, 3.24). However, there was no significant difference in age or sex between the recurrence group and the non-recurrence group. Findings from one or two cohort studies also indicated that the copresence of HLA-B*18:01 and -B*35, the number of days required to taper prednisolone (PSL) to 5 mg/day, the duration of disease before treatment less than 30 days, the sialic acid level, or the TSH level at the termination of treatment and further extension of the hypoechoic area and increase in thyroid volume were related to the recurrence of SAT.

CONCLUSION

Recurrence was common in SAT patients. The present study indicated that glucocorticoid treatment was associated with a higher recurrence rate of SAT than NSAIDs treatment. The clinical implications of this association should be interpreted with caution, and further clinical trials on the long-term effects of different treatment strategies are needed.

SUBACUTE THYROIDITIS IN A PATIENT WITH CORONAVIRUS DISEASE 2019

Objective

Subacute thyroiditis (SAT) is an inflammatory disorder of the thyroid gland that causes destructive thyrotoxicosis and is attributed to a viral or post-viral response. SARS-CoV-2 is a novel coronavirus that caused a global pandemic in 2020. We present a case that suggests that there may be a relationship between SAT and corona-virus disease 2019 (COVID-19).

Methods

We describe the clinical findings, thyroid function tests, and neck ultrasound of a patient presenting with anterior neck pain.

Results

A 47-year-old, Filipino female presented with anterior neck pain associated with neck tenderness and goiter. She did not have fever or respiratory symptoms but had right lower lobe pneumonia on chest radiograph. Thyroid function tests were consistent with subclinical hyperthyroidism with thyroid-stimulating hormone of 0.05 μIU/mL (reference range is 0.47 to 4.68 μIU/mL), free thyroxine of 1.68 pg/mL (reference range is 0.78 to 2.19 pg/mL), and total triiodothyronine of 1.4 ng/mL (reference range is 0.97 to 1.69 ng/mL). Anti-thyroid peroxidase, anti-thyroglobulin, and thyroid-stimulating hormone receptor antibodies were negative. Neck ultrasound showed heterogenous thyroid tissues with normal vascularity. Reverse transcription-polymerase chain reaction for SARS-CoV-2 using nasopharyngeal and oropharyngeal swabs were positive. The patient was diagnosed as having SAT and was treated with mefenamic acid, which was later switched to celecoxib. Ceftriaxone and hydroxychloroquine were started for COVID-19 pneumonia. Complete resolution of symptoms and primary hypothyroidism occurred after 2 months.

Conclusion

SAT may be a presenting symptom or a sequela of COVID-19. Histopathology studies and definitive documentation of the virus in thyroid tissues may be required to confirm the relationship between SAT and COVID-19.

Efficacy and safety of Xiaochaihu decoction for subacute thyroiditis: A protocol of systematic review and meta-analysis

BACKGROUND

Subacute thyroiditis (SAT) is a transient and self-limiting inflammatory thyroid disease. There is no clear evidence for specific etiology, but it is generally thought to occur after viral infection. Characteristics of SAT include severe pain of the anterior neck, enlarged firm thyroid, disordered thyroid function, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), typical ultrasound findings (hypoechoic areas) and low thyroid uptake of radioactive iodine or technetium-99 m because of the destructive etiology of the hyperthyroidism. Evidences showed Xiaochaihu decoction (XCHD) has a significant effect on improving the symptoms of SAT patients. The purpose of this study is to assess the safety and effectiveness of XCHD for patients with SAT.

METHODS AND ANALYSIS

The literature that has been identified via searching 6 Chinese electronic databases and eight English electronic databases from inception to September 21, 2020 will be included in the study. Research selection, data extraction as well as research quality assessment will be completed by 2 experienced researchers independently. The primary outcome is remission rate. Data analysis will be conducted by the RevMan 5 software, and GRADE will help to assess the level of evidence. The heterogeneity of data will be investigated by a heterogeneity x test, as well as the Higgins I test. A subgroup analyses and sensitivity analysis will be conducted to explore the sources of heterogeneity.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

This study will draw a conclusion about whether XCHD is safe and effective in treating SAT on the basis of evidence-based medicine. This conclusion will provide areliable scientific evidence for the alternative treatment for the management of SAT. OSF REGISTRATION NUMBER:: https://osf.io/8hbue.

Higher thyroid hormone levels and cancer

PURPOSE

This narrative review aims to summarize the relationship between hyperthyroidism, upper reference range thyroid hormone (TH) levels, and cancer, and to address the clinical management of hyperthyroidism in cancer patients.

METHODS

A comprehensive search was performed by an independent reviewer through Google Scholar and PubMed Electronic databases. All searches were restricted to English language manuscripts published between 2000 and 2020.

RESULTS

Numerous in vitro, in vivo, and population-based studies suggest cancer-stimulating effect of triiodothyronine and thyroxin. THs are presented as mediators for tumor growth, proliferation, and progression. Many population and case-control studies suggest an increased risk of several solid but also hematologic malignancies in relation to hyperthyroidism and upper normal range TH levels. However, results are not unambiguous. In this review, we will summarize population and case-control studies that investigated the relationship between hyperthyroidism, upper reference range TH levels, lower thyrotropin (TSH) levels, lower reference range TSH levels with cancer risk, cancer prognosis, and cancer outcome. The vast majority of evidence suggests an association between clinical and subclinical hyperthyroidism with the risk of developing several types of cancer. Furthermore, hyperthyroidism is also linked with a poorer cancer prognosis. In this review, we will also discuss the diagnosis of hyperthyroidism in patients with pre-existing cancer and cover the management of hyperthyroidism in cancer patients, with special attention on the role of nuclear medicine.

CONCLUSIONS

It is crucial to emphasize the importance of the rapid establishment of euthyroidism, and consequently, the importance of radioiodine therapy, as the therapy of choice in most cancer patients. We want to show that in this day and age there still is a high relevance for I-131 to achieve a permanent solution and thus likely reduce the risk of adverse influence of hyperthyroidism on the occurrence of new and course of existing cancer cases.

Infiltration of the thyroid gland by non-thyroid malignancy: A literature review reveals this to be an unusual cause of hyperthyroidism

Background

Non-thyroid malignancies that metastasize to the thyroid gland are relatively rare. At one end of the spectrum they may only be identified at the time of autopsy. At the other extreme, they may be identified during the evaluation of a progressive malignancy. Most patients who are identified as having metastases to their thyroid gland are euthyroid, but some patients may have associated hypothyroidism or hyperthyroidism. This review examines cases of hyperthyroidism associated with metastases affecting the thyroid gland.

Results

Twenty four articles describing 26 cases of malignancy-associated hyperthyroidism were identified, with the cases presenting with features suggestive of a thyroiditis and with goiter. The solid malignancies (19 cases) were mostly breast and lung cancer. Hematologic malignancies (7 cases) were also reported with a similar thyroiditis-like presentation. Patients underwent the traditional work-up for a thyroiditis, but frequently underwent other radiographic studies, in addition to radioactive iodine imaging, and frequently also underwent thyroid biopsy. The course in most patients (22/26 cases) was progression from hyperthyroidism to hypothyroidism, as the underlying malignancy progressed or thyroidectomy was performed, or the patient succumbed to their malignancy. Some patients (4 cases) became euthyroid with successful treatment of their malignancy. A subset of patients (5 cases) initially presented with severe thyrotoxicosis. Many affected patients succumbed to their underlying malignancy.

Conclusion

Malignancy-associated hyperthyroidism has a similar underlying mechanism to subacute thyroiditis, in so much as there is damage or destruction of thyroid tissue. In cases of subacute thyroiditis this damage is self-limited, and there is recovery of thyroid function. In some cases of thyroiditis associated with malignancy there may be thyroid gland recovery as the underlying malignancy is treated and controlled. However, if the malignancy progresses, eventual hypothyroidism is likely to ensue.

Subacute Thyroiditis is Associated with HLA-B*18:01, -DRB1*01 and -C*04:01-The Significance of the New Molecular Background

Subacute thyroiditis (SAT) is a thyroid inflammatory disease whose pathogenesis is still not completely defined. Previous viral infection is considered to be a triggering factor in genetically predisposed individuals. In about 70% of patients, susceptibility to SAT is associated with the HLA-B*35 allele. The correlation between SAT and other human leukocyte antigens (HLA) has not yet been unequivocally demonstrated and the genetic background is still unknown in about 30% of patients. The purpose of our study was to perform HLA genotyping using a next-generation sequencing method, to find out whether alleles other than HLA-B*35 are correlated with SAT morbidity. HLA-A, -B, -C, -DQB1, -DRB1 were genotyped using a next-generation sequencing method in 1083 subjects, including 60 SAT patients and 1023 healthy controls. Among 60 patients diagnosed with SAT, 81.7% of subjects were identified as having allele HLA-B*35, 23.3% had HLA-B*18:01, 28.3% had HLA-DRB1*01 and 75.5% had HLA-C*04:01. These alleles occurred in the control group at frequencies of 10.2%, 7.2%, 12.9% and 12.5%, respectively. The differences were statistically significant, with p < 0.05. In addition to its previously described relationship with HLA-B*35, genetic susceptibility to SAT was associated with the presence of HLA-B*18:01, DRB1*01 and C*04:01. The alleles HLA-B*18:01 and DRB1*01 were independent SAT risk factors. The assessment of these four alleles allows the confirmation of genetic predisposition in almost all patients with SAT.

Two-Years Prospective Follow-Up Study of Subacute Thyroiditis

Purpose: The aim of the present prospective follow-up study was to explore the early indicators of hypothyroidism and the final changes in thyroid volume in subacute thyroiditis (SAT) patients. Methods: We enrolled 61 SAT patients and followed them up for 2 years to assess the incidence of hypothyroidism and changes in thyroid volume. Binary logistic regression and receiver operating characteristic (ROC) curves were used for data analysis. Results: During the 2 years follow-up period, we found that the volumes of the thyroid gland in SAT patients at 1 and 2 years were significantly smaller than those in the healthy control group, which were significantly smaller compared to the initial thyroid volumes after SAT onset (p < 0.001). Also, the thyroid volumes of SAT patients with hypothyroidism were significantly smaller than those of SAT patients without hypothyroidism. The early maximum thyroid-stimulating hormone (TSH) values (within 3 months after SAT onset) were closely related to the incidence of hypothyroidism at 2 years. The OR value was 1.18 (95% CI = 1.01-1.38, p = 0.032). The early maximum TSH value had a maximum area under the ROC curve (AUC) of 0.866 for the development of hypothyroidism 2 years after SAT onset vs. euthyroidism (p < 0.001). Conclusions: The thyroid volumes of patients increased significantly after the onset of SAT, while during the follow-up these volumes decreased; the thyroid volumes at 1 and 2 years were significantly smaller than those of normal healthy subjects, especially in SAT patients with hypothyroidism. Furthermore, the early maximum TSH value could be used as an effective indicator of the development of hypothyroidism 2 years after the onset of SAT.

Thyroid primary and metastatic malignant tumours of poor prognosis may mimic subacute thyroiditis - time to change the diagnostic criteria: case reports and a review of the literature

BACKGROUND

The diagnosis of subacute thyroiditis (SAT) is based mainly on the presence of painful thyroid goitre and a significant increase in erythrocyte sedimentation rate (ESR). Proceeding according to these diagnostic criteria may lead to an incorrect diagnosis and treatment. Extremely dangerous is the situation when the diagnosis of SAT is erroneously made based on criteria other than ultrasound (US) image and fine needle aspiration biopsy (FNAB), which leads to delayed diagnosis of malignant tumour with poor prognosis.

CASE PRESENTATION

Five patients with typical SAT symptoms are presented. In all of them, anaplastic thyroid cancer or metastatic thyroid tumours were finally diagnosed as the cause of the initial symptoms resembling SAT. Most of the patients were initially misdiagnosed and the proper diagnosis of malignancy was delayed.

CONCLUSIONS

The authors have proposed the new diagnostic criteria for SAT, and strongly suggest that thyroid gland US should be included in the main criteria of SAT diagnosis, together with FNAB result excluding the presence of malignant tumour.

Vitamin D supplementation for the prevention or depletion of side effects of therapy with alemtuzumab in multiple sclerosis

PURPOSE OF REVIEW

Not only the multiple sclerosis specialist but also the general neurologist and primary care practitioner are increasingly aware of possible adverse events (AEs) by treatment with alemtuzumab (over 47% risk of secondary autoimmune-mediated diseases). Vitamin D supplementation's effect (VDS) to reduce these autoimmune AEs is poorly performed in routine practice. This article seeks to justify why this simple, inexpensive, patient-friendly therapy should be seriously discussed.

RECENT FINDINGS

Patients who have developed autoimmunity also show a high basal level of IL-21, a cytokine which increases the growth of auto-reactive T-cells. For side effects such as thyroid dysfunction, autoimmune thrombocytopenia, autoimmune hemolytic anemia, autoimmune hepatitis, diabetes mellitus type 1, and alopecia areata/alopecia totalis, VDS may have an impact on the immunological mechanism, in particular lowering levels of IL-17 and IL-21.

SUMMARY

The potential role of vitamin D in influencing autoimmune diseases is evident. If a life-threatening side-effect can be prevented by high-dose VDS, it is ethical to initiate this add-on therapy despite contradictory results in studies on the effectiveness of VDS.

Thyroid nodules: diagnosis and management

Thyroid nodules are common. Their importance lies in the need to assess thyroid function, degree of and future risk of mass effect, and exclude thyroid cancer, which occurs in 7-15% of thyroid nodules. There are four key components to thyroid nodule assessment: clinical history and examination, serum thyroid stimulating hormone (TSH) measurement, ultrasound and, if indicated, fine-needle aspiration (FNA). If the serum TSH is suppressed, a thyroid scan with ⁹⁹Tc can distinguish between a solitary hot nodule, a toxic multinodular goitre or, less commonly, thyroiditis or Graves' disease within a coexisting nodular thyroid. Scintigraphically cold nodules are evaluated in the same way as in the setting of normal or elevated serum TSH levels. Thyroid ultrasonography should be performed only for palpable goitre and thyroid nodules and by specialists with expertise in thyroid sonography. Routine thyroid cancer screening is not recommended, except in high risk individuals, as the detection of early thyroid cancer has not been shown to improve survival. FNA may be performed for nodules ≥ 1.0 cm depending on clinical and sonographic risk factors for thyroid cancer. FNA specimens should be read by an experienced cytopathologist and be reported according to the Bethesda Classification System. Molecular analysis of indeterminate FNA samples has potential to better discriminate benign from malignant nodules and thus guide management. Surgery is indicated for FNA findings of malignancy or indeterminate cytology when there is a high risk clinical context. Surgery may also be indicated for suspicion of malignancy; larger nodules, especially with symptoms of mass effect; and in some patients with thyrotoxicosis.

Management of Endocrinopathies in Pregnancy: A Review of Current Evidence

Pregnancy in women with associated endocrine conditions is a therapeutic challenge for clinicians. These disorders may be common, such us thyroid disorders and diabetes, or rare, including adrenal and parathyroid disease and pituitary dysfunction. With the development of assisted reproductive techniques, the number of pregnancies with these conditions has increased. It is necessary to recognize symptoms and correct diagnosis for a proper pharmacotherapeutic management in order to avoid adverse side effects both in mother and fetus. This review summarizes the pharmacotherapy of these clinical situations in order to reduce maternal and fetal morbidity.

The Risk of Recurrence of Subacute Thyroiditis Is HLA-Dependent

The frequency of recurrence of subacute thyroiditis (SAT) is rather high, reaching 20–30%. The reason for SAT relapse is still unknown. Recently, we have demonstrated the association between SAT and the presence of HLA-B*18:01, DRB1*01, and C*04:01, apart from the previously known HLA-B*35. The aim of the present study was to evaluate the correlation between SAT-associated HLA haplotypes and the risk of SAT recurrence. HLA-A, -B, -C, -DQB1 and -DRB1 were genotyped using a next-generation sequencing method in 49 SAT patients. The patients were divided into the following HLA groups: 1. HLA-B*35 and/or HLA-C*04, but without any other of the analyzed antigens; 2. HLA-DRB1*01, regardless of the co-presence of HLA-B*35 or -C*04:01, but without HLA-B*18:01; 3. HLA-B18 only, without any other antigen; 4. HLA-B*18:01 plus -B*35, regardless of the presence of any other analyzed antigens. The recurrence rate was compared between the groups. The recurrence rate was significantly increased in patients with HLA-B*18:01 plus HLA-B*35. In conclusion, the risk of SAT recurrence was HLA-dependent and the determining factor was the co-presence of HLA-B*18:01 and -B*35. In such high-risk patients, the steroid treatment regimen should be intensified with a slower dose reduction.

Sonographic Pattern of Subacute Thyroiditis Is HLA-Dependent

Background: Since 1977 the susceptibility to SAT has been known to be HLA-B*35-related in ~70% of patients. Recently it has been demonstrated that SAT is associated with the presence of HLA-B*18:01 and DRB1*01, as well as with HLA-C*04:01. The association between the type of genetic SAT background and sonographic pattern of the disease has never been analyzed. The aim of the study was to evaluate the potential correlation between the presence of individual HLA haplotypes and the sonographic SAT pattern, and to provide the US characteristics of the analyzed SAT cases. Methods: HLA-A, -B, -C, -DQB1, and -DRB1 were genotyped using a next-generation sequencing method in 46 SAT patients. All patients were divided into the following groups according to the HLA haplotype: 1. HLA-B*35 and/or HLA-C*04, but without any other of the analyzed antigens; 2. HLA-DRB1*01, regardless of the co-presence of HLA-B*35 or C*04:01, but without HLA-B*18:01; 3. HLA-B*18:01 only, without any other of the analyzed antigens; 4. HLA-B*18:01 plus B*35, regardless of the presence of any other analyzed antigens. The US patterns of SAT thyroid lesions were compared among the groups. Results: The US image of SAT lesions in Groups 1 and 2 were similar. The typical SAT features for these groups were as follows: hypoechoic, strongly heterogeneous, bilateral, multiple areas, with decreased vascularization, usually oval with blurred margins, infrequently affecting the whole lobe, or having nodule-like pattern. Several features of Group 3 were different from the other groups. In 60% of cases lesions were rather homogeneous, and in 100%-hypoechoic, in 80% of patients there was only one unilateral single SAT area filling the whole affected lobe. On the contrary to the other groups, in Group 4 no lesion was oval in shape. Conclusions: Our results provide for the first time the evidence that the US pattern of SAT lesions depends on HLA, and the determining factor is the presence of HLA-B*18:01. The deviations from the typical SAT US image are mostly pronounced in patients with the presence of only HLA-B*18:01, without any other analyzed haplotype. Further research is necessary to explain this phenomenon.