Graves' disease following vaccination against SARS-CoV-2: A systematic review of the reported cases

Increased incidence of Graves' disease during the COVID-19 pandemic in children and adolescents in the United States

Introduction

Reports in adults indicate that Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2) infection and vaccination trigger the expression of autoimmune disease such as Graves' disease, but the incidence of new onset Graves' disease and its temporal relationship to the peaks of COVID-19 cases in children are unclear.

Methods

This is a retrospective study of children and adolescents with new-onset Graves' disease diagnosed between September 2017 and August 2022, N=156, mean age of 12.5 ± 4 year (y), with a range of 2.9-17.9y. There were 119 female (76.3%) and 37 male (23.7%) subjects. Subjects were categorized into 2 groups: pre-COVID-19 era Graves' disease (n=63, age 12.5 ± 3.3y), and COVID-19 era Graves' disease (n=93, age 12.4 ± 4.4y). We calculated incidence rate based on new cases of Graves' disease and total number of new patient referrals to our endocrine clinic. We first compared the demographic, clinical and biochemical data between the above 2 groups; and also, between subjects with either a history of COVID-19 infection (n=23) or vaccination (n=17) to a control group (n=63).

Results

The incidence of Graves' disease was significantly higher during the pandemic: pre-COVID-19 versus the COVID-19 era, n=55, 0.56% vs n=93, 0.9%, p=0.005, after accounting for the total number of annual new patient referrals during the study period. The rise in the cases of Graves' disease followed the spikes in the number of cases of COVID-19 in NY. There was also a statistically significant difference in the race distribution between the pre-COVID-19 and the COVID-19 era (p=0.026).

Discussion

The incidence of Graves' disease increased significantly in children living in New York during the COVID-19 pandemic. The temporal relationship between the peaks of COVID-19 cases and the increased cases of new onset Graves' disease suggest possible autoimmune triggering by SARS-CoV-2.

COVID-19 Vaccines: A Radiological Review of the Good, the Bad, and the Ugly

The World Health Organization has declared "with great hope" an end to COVID-19 as a public health emergency. The vaccination drive that started in December 2020 played a crucial role in controlling the pandemic. However, the pace at which COVID-19 vaccines were developed and deployed for general population use led to vaccine hesitancy, largely owing to concerns regarding the safety and efficacy of the vaccines. Radiology has been instrumental in demonstrating the extent of pulmonary involvement and identification of the complications of COVID-19, and the same holds true for vaccine-related complications. This review summarizes the existing body of radiological literature regarding the efficacy, adverse events, and imaging pitfalls that accompany the global rollout of various COVID-19 vaccines.

SARS-CoV-2-Vaccine-Related Endocrine Disorders: An Updated Narrative Review

The emergence of the COVID-19 pandemic has led to the rapid and worldwide development and investigation of multiple vaccines. While most side effects of these vaccines are mild and transient, potentially severe adverse events may occur and involve the endocrine system. This narrative review aimed to explore the current knowledge on potential adverse endocrine effects following COVID-19 vaccination, with thyroid disorders being the most common. Data about pituitary, adrenal, diabetes, and gonadal events are also reviewed. This review also provides a comprehensive understanding of the pathogenesis of endocrine disorders associated with SARS-CoV-2 vaccines. PubMed/MEDLINE, Embase database (Elsevier), and Google Scholar searches were performed. Case reports, case series, original studies, and reviews written in English and published online up to 31 August 2023 were selected and reviewed. Data on endocrine adverse events of SARS-CoV-2 vaccines are accumulating. However, their causal relationship with COVID-19 vaccines is not strong enough to make a definite conclusion, and further studies are needed to clarify the pathogenesis mechanisms of the endocrine disorders linked to COVID-19 vaccines.

Thyroid storm after coronavirus disease 2019 mRNA vaccination in a patient with a history of Graves' disease after coronavirus disease 2019 infection

We report a case where the patient may have developed Graves' disease after COVID-19 infection, and where the COVID-19 vaccination may have exacerbated the condition, inducing the onset of a thyroid storm. Although any association between the vaccine and the onset of thyroid disease is impossible to demonstrate through a single case, the antecedent COVID-19 infection and COVID-19 messenger ribonucleic acid vaccination may have synergistically contributed to the development of Graves' disease followed by thyroid storm.

Thyroid dysfunction in COVID-19

The COVID-19 pandemic has affected over 772 million people globally. While lung damage is the major contributor to the morbidity and mortality of this disease, the involvement of multiple organs, including the endocrine glands, has been reported. This Review aims to provide an updated summary of evidence regarding COVID-19 and thyroid dysfunction, incorporating highlights of recent advances in the field, particularly in relation to long COVID and COVID-19 vaccination. Since subacute thyroiditis following COVID-19 was first reported in May 2020, thyroid dysfunction associated with COVID-19 has been increasingly recognized, secondary to direct and indirect effects on the hypothalamic-pituitary-thyroid axis. Here, we summarize the epidemiological evidence, pattern and clinical course of thyroid dysfunction following COVID-19 and examine radiological, molecular and histological evidence of thyroid involvement in SARS-CoV-2 infection. Beyond acute SARS-CoV-2 infection, it is also timely to examine the course and implication of thyroid dysfunction in the context of long COVID owing to the large population of survivors of COVID-19 worldwide. This Review also analyses the latest evidence on the relationship between the therapeutics and vaccination for COVID-19 and thyroid dysfunction. To conclude, evidence-based practice recommendations for thyroid function testing during and following COVID-19 and concerning COVID-19 vaccination are proposed.

Minimal change disease following COVID-19 vaccination: A systematic review

BACKGROUND

The newly developed COVID-19 vaccines are highly effective and safe. However, a small portion of vaccine recipients experience a wide range of adverse events. Recently, glomerular disease, including the development of Minimal Change Disease (MCD), has been observed after administration of different COVID-19 vaccines, although causality remains a matter of debate.

AIM

The aim of this systematic review was to comprehensively examine the available literature and provide an overview of reported cases of MCD following vaccination against SARS-CoV-2.

RESULTS

We identified 46 eligible articles which included 94 cases with MCD following COVID-19 vaccination of which one case was reported twice due to a second relapse. Fifty-five participants were males (59.1%, 55/93) and 38 (40.9%, 38/93) were females with a mean age of 45.02 years (SD:20.95). From the included patients 50 (50/94, 53.1%) were described as new-onset and 44 (46.9%, 44/94) as relapse. On average, symptomatology developed 16.68 days (SD: 22.85) after the administration of the vaccine irrespective of the dose. Data about symptoms was reported in 68 cases with the most common being oedema (80.8%, 55/68), followed by weight gain (26.5%, 18/68) and hypertension (16.1%, 11/68). In terms of outcome, more than half of the patients went into remission (61%, 57/94), while 18 recovered or improved post treatment (19.1%, 18/94). Two people relapsed after treatment (2.1%, 2/94) and two cases (2.1%, 2/94) were reported as not recovered.

CONCLUSION

MCD is possibly a condition clinicians may see in patients receiving COVID-19 vaccines. Although this adverse event is uncommon, considering the limited published data and the absence of confirmed causality, increased clinical awareness is crucial for the early recognition and optimal management of these patients.

Development of autoimmune thyroid disease after COVID-19 infection: case report

Background

SARS-CoV-2 could trigger multiple immune responses, leading to several autoimmune diseases, including thyroid diseases. Many cases of thyroid diseases caused by COVID-19 infection have been reported. Here, we describe the disease development of patients with autoimmune thyroid disease after COVID-19 infection.

Methods

The clinical characteristics, diagnosis and treatment of five different patients with autoimmune thyroid disease after COVID-19 infection were reported.

Results

Female patients with primary autoimmune thyroid disease which have been stable for many years were reported. One month after COVID-19 infection, the disease has undergone different evolution. Case 1, a patient with history of long-term stable Hashimoto's thyroiditis, suddenly suffered from Graves disease after COVID-19 infection. Case 2, a patient with history of long-term stable Hashimoto's thyroiditis with thyroid nodules, suddenly suffered from Graves disease after infection. Case 3, a patient with history of long-term stable Graves disease, suddenly suffered from worsening after infection. The above three cases showed thyroid-stimulating antibodies were enhanced. Case 4, a patient with history of previous hypothyroidism had an increase in thyroid-related antibody (TPOAb and TRAb) activity after infection, followed by a marked worsening of hypothyroidism. Case 5, a patient with no history of thyroid disease suddenly developed controllable "thyrotoxicosis" after infection, suggesting the diagnosis of painless thyroiditis.

Conclusion

The five case reports show a different development of the primary autoimmune thyroid disease after COVID-19 infection. The change in the trend of thyroid disease is closely related to the immune response induced by SARS-CoV-2 infection.

Graves' Disease Following COVID-19 Vaccination: A Population-based, Matched Case-control Study

OBJECTIVE

Multiple cases and case series reported Graves' disease (GD) following coronavirus disease 2019 (COVID-19) vaccination. We aimed to determine whether COVID-19 vaccination was associated with the incidence of GD.

METHODS

We analyzed data from Clalit Health Services, the largest healthcare organization in Israel, which insures 4.7 million patients. A population-based, matched, case-control study was performed. Cases were defined as adult patients diagnosed with GD between December 2020 and November 2022. Each case was matched with controls in a 1:2 ratio. Each control was assigned an index date, which was identical to that of their matched case, defined as the date of GD diagnosis. Time between vaccination date and the diagnosis of GD or index date was assessed.

RESULTS

A total of 726 patients with GD were matched with 1452 controls. The study patients and controls have received similar proportions of the COVID-19 vaccine [at least 1 dose: 80% (581/726) vs 77.8% (1129/1452), P = .22, respectively]. In a univariate analysis, at least 1 dose of the COVID-19 vaccine was not associated with the incidence of GD [odds ratio 95% confidence interval: 1.15 (.92-1.43)]. The mean time between first COVID-19 vaccination and the diagnosis of GD for cases or index date for controls was not significantly different [275.69 days (SD 144.37) for cases compared to 275.45 days (SD 145.76) for controls].

CONCLUSION

Our study found no association between COVID-19 vaccination and the incidence of GD.

Graves' disease post-COVID-19 m-RNA vaccine in pediatric age group

The surge of the COVID-19 pandemic (December / 2019 - May/2023) and its catastrophic effect worldwide have necessitated emergent intervention to reduce its influence on people's health and life. To eliminate and reduce the impact of COVID-19 infection, COVID-19 vaccination was emergently authorized in December 2020 which has established good safety and efficacy. Having said that, some adverse effects merged in a few individuals. We are reporting an adolescent patient a 17-year-old female who has been diagnosed with Graves' disease after post-COVID-19 vaccinations. In addition, she was a confirmed case of COVID-19 infection three months earlier. The patient presented with typical features of hyperthyroidism 30 days post receiving the first dose of the vaccination. Based on the patient's presentation relative to the administration of the vaccine and prior infection of the virus. We proposed the synergistic effect of both factors to induce Graves' disease in this young healthy female with no family history of autoimmune disease. We are reporting this case for pediatric endocrinologists to be aware of the interaction and possible impact of the COVID-19 vaccine on thyroid function.

COVID-19 induced type 1 diabetes: A systematic review of case reports and series

AIMS

To provide an overview of reported cases of new-onset type 1 diabetes mellitus (T1D) following COVID-19 infection.

METHODS

PubMed and Scopus library databases were screened for relevant case reports published between January 2020 and June 2022. Study design, geographic region or language were not restricted.

RESULTS

Twenty studies were identified and involved 37 patients (20 [54%] male, 17 [46%] female). Median age was 11.5 years (range 8 months-33 years) and 31 (84%) patients were aged ≤17 years. Most patients (33, 89%) presented with diabetic ketoacidosis (DKA). In total, 23 (62%) patients presented at the time of positive COVID-19 testing and 14 (38%) had symptoms consistent with COVID-19 infection or a previous positive test (1-56 days). Diabetes symptomatology was provided in 22 cases and (19, 86%) reported polyuria, polydipsia, polyphagia, fatigue, or weight loss or a combination of the aforementioned in the preceding weeks (3 days-12 weeks). Of the 28 patients that had data on acute and long-term treatment, all recovered well and most were managed with basal bolus insulin regimens. Quality assessment showed that most reports were either 'good' or 'moderate quality'.

CONCLUSIONS

Although uncommon, new-onset T1D is a condition healthcare professionals may expect to see following a COVID-19 infection.

Graves' disease after COVID mRNA vaccination for the first time diagnosed in adolescence-case report. Cause and effect relationship or simple coincidence?

OBJECTIVES

Over the past 3 years, coronavirus disease 2019 with its worldwide spread has profoundly marked public health, therefore anti-COVID-19 vaccinations have been developed to prevent the dissemination of the disease. To date, 71 cases of Graves' disease (GD) after vaccination against SARS-Cov-2 were described in the adult population. Our goal is to present the first case in the paediatric population.

CASE PRESENTATION

We present the first case of a 16-year-old adolescent girl who developed GD 6-7 weeks after the second dose anti-COVID-19 mRNA vaccine. Therapy with methimazole and propranolol was started, achieving normal thyroid function and negativity of thyroid autoantibodies at the time of therapy discontinuation after 8 months.

CONCLUSIONS

This case shows that the development of GD after COVID-19 mRNA vaccination can occur also in the adolescent population. Nevertheless, the small number of cases of GD described so far, after many millions of vaccinations, makes it impossible to determine whether this is simple a coincidence or a cause. Further epidemiological data on the incidence of GD in the vaccination period compared to the previous period will be able to clearly define this question.

The Incidence of Graves' hyperthyroidism before and After COVID-19 mRNA Vaccination

OBJECTIVE

Case reports of post vaccine early-onset Graves' hyperthyroidism (PVGD) after the administration of corona virus disease-19 (COVID-19) vaccination have emerged. Our aim was to investigate whether the incidence of Graves' hyperthyroidism (GD) has increased after the introduction of COVID-19 vaccination.

METHODS

We compared the incidence of new-onset GD at a single academic center during two periods: December 2017-October 2019 and December 2020-October 2022; i.e., before and after implementation of COVID-19 vaccinations. We defined PVGD as laboratory-confirmed hyperthyroidism and GD within 4 weeks after the vaccination or patients who reported clear onset of symptoms of thyrotoxicosis within 4 weeks of vaccination with evidence of hyperthyroidism and GD within 3 months.

RESULTS

During the pre-vaccination period, 803 patients carried diagnoses of GD, and of these, 131 were new. During the post-vaccination period, 901 patients carried diagnoses of GD, and of these, 138 were new. There was no statistically significant difference in the incidence of GD (p=0.52), age at onset, gender, or race between the two groups. Twenty-four patients out of 138 newly diagnosed patients in the post-COVID group met the criteria for PVGD. The median free T4 was higher, but this was not statistically significant (3.9 vs. 2.5 ng/dl, p=0.05). There were no differences in age, gender, race, antibody titers, or type of vaccination between PVGD and controls.

CONCLUSION

There was no increase of new-onset GD after COVID vaccination. Median free T4 was higher in patients with PVGD, but this was not statistically significant.

Graves' disease after exposure to the SARS-CoV-2 vaccine: a case report and review of the literature

BACKGROUND

Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) is characterized by immune system dysregulation after exposure to adjuvants, such as aluminum. Although cases of autoimmune thyroid diseases caused by ASIA have been reported, Graves' disease is one of the rarer diseases. There are some reports that vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cause ASIA. Here, we describe a case of Graves' disease following SARS-CoV-2 vaccination and a review of the literature.

CASE PRESENTATION

A 41-year-old woman was admitted to our hospital because of palpitations and fatigue. Two weeks after receiving the second SARS-CoV-2 vaccine (BNT162b2, Coronavirus Modified Uridine messenger RNA (mRNA) Vaccine, Pfizer), she developed fatigue and gradually worsened. On admission, she exhibited thyrotoxicosis (thyroid-stimulating hormone (TSH) < 0.01 mIU/L (0.08-0.54), free triiodothyronine (FT3) 33.2 pmol/L (3.8-6.3), and free thyroxine (FT4) 72.1 pmol/L (11.6-19.3)) and palpitations associated with atrial fibrillation. TSH receptor antibody (TRAb) was positive (TRAb 5.0 IU/L (< 2.0)), and ^99mTc scintigraphy showed diffuse uptake in the thyroid gland, suggesting that the thyrotoxicosis in this case was caused by Graves' disease. Thiamazole was prescribed to correct her condition, and soon after this treatment was initiated, her symptoms and thyroid hormone levels were significantly reduced.

CONCLUSIONS

This case report reinforces the potential correlation between ASIA affecting the thyroid and SARS-CoV-2 mRNA vaccines. The clinical course suggests that it is essential to consider the possibility of developing ASIA, such as Graves' disease, after exposure to the SARS-CoV-2 vaccine.