Subacute THYROiditis Related to SARS-CoV-2 VAccine and Covid-19 (THYROVAC Study): A Multicenter Nationwide Study

CONTEXT

The aims of the study are to compare characteristics of subacute thyroiditis (SAT) related to different etiologies, and to identify predictors of recurrence of SAT and incident hypothyroidism.

METHODS

This nationwide, multicenter, retrospective cohort study included 53 endocrinology centers in Turkey. The study participants were divided into either COVID-19-related SAT (Cov-SAT), SARS-CoV-2 vaccine-related SAT (Vac-SAT), or control SAT (Cont-SAT) groups.

RESULTS

Of the 811 patients, 258 (31.8%) were included in the Vac-SAT group, 98 (12.1%) in the Cov-SAT group, and 455 (56.1%) in the Cont-SAT group. No difference was found between the groups with regard to laboratory and imaging findings. SAT etiology was not an independent predictor of recurrence or hypothyroidism. In the entire cohort, steroid therapy requirement and younger age were statistically significant predictors for SAT recurrence. C-reactive protein measured during SAT onset, female sex, absence of antithyroid peroxidase (TPO) positivity, and absence of steroid therapy were statistically significant predictors of incident (early) hypothyroidism, irrespective of SAT etiology. On the other hand, probable predictors of established hypothyroidism differed from that of incident hypothyroidism.

CONCLUSION

Since there is no difference in terms of follow-up parameters and outcomes, COVID-19- and SARS-CoV-2 vaccine-related SAT can be treated and followed up like classic SATs. Recurrence was determined by younger age and steroid therapy requirement. Steroid therapy independently predicts incident hypothyroidism that may sometimes be transient in overall SAT and is also associated with a lower risk of established hypothyroidism.

A Case of New-onset Autoimmune Type-1 Diabetes Mellitus Following COVID-19 Infection

BACKGROUND

After COVID-19 infection, various mechanisms may initiate an increased risk of developing DM. This study presented a newly developed autoimmune Type 1 DM (T1DM) case in an adult patient after a SARS-CoV-2 infection.

CASE PRESENTATION

A 48-year-old male patient presented with complaints of weight loss and blurred vision. His blood sugar and HbA1c were measured as 557 mg/dl and 12.6%, respectively. His medical records showed no known diagnosis of DM. He had a SARS-CoV-2 infection 4 weeks ago. Then, we diagnosed DM and started basal-bolus insulin therapy. C-peptides and autoantibodies were requested from the patient to explore the etiology of diabetes. Glutamic acid decarboxylase (GAD) antibody was > 2000 U/mL (ref: 0-10); therefore, the patient was accepted as having autoimmune T1DM. New-onset DM cases triggered by COVID-19 have increasingly been reported recently. SARS-CoV-2 virus, using the ACE2 receptor in the pancreas, can enter beta cells and causes damage to these islets and impaired insulin secretion, leading to acute diabetes mellitus. In addition, the abnormal immunity elicited by SARS-CoV-2 can also induce autoimmune destruction of pancreatic islet cells.

CONCLUSION

T1DM may be an uncommon but possible complication due to the COVID-19 virus among genetically predisposed individuals. Overall, the case highlights the importance of preventive measures, such as vaccination, to protect against COVID-19 and its complications.

A Case Report of Concurrent Graves' Disease and Subacute Thyroiditis Following SARS-CoV-2 Vaccination: An Autoimmune/Inflammatory Syndrome (ASIA)

BACKGROUND

The response against adjuvants in vaccines is presented as autoimmune/inflammatory syndrome (ASIA). In this case report, we presented both SAT and Graves' disease in a patient as ASIA following the BNT162b2 mRNA COVID-19 vaccination.

CASE PRESENTATION

A 31-year-old woman was admitted to the endocrinology outpatient clinic with the complaint of neck pain following the second dose of the BNT162B2 SARS-CoV-2 (Pfizer/BioNTech) vaccine. On physical examination, her thyroid gland was tender on palpation. Her thyroid function tests were compatible with hyperthyroidism, and inflammatory markers were high. In the thyroid ultrasonography (US) examination, we observed bilateral diffuse hypoechoic areas in the thyroid gland and increased vascularity in some parts of the thyroid. Anti-thyroid stimulating hormone receptor antibodies (TRAB) were positive. Overall, we considered concurrent subacute thyroiditis (SAT) and Graves' disease.

CONCLUSION

The present study may be the first report to evaluate SAT and Graves' disease as ASIA following mRNA COVID-19 vaccination. Clinicians should be aware of possible vaccine-related complications.

A Case Report of Conversion from Hashimoto's Thyroiditis to Graves' Disease in Type 1 Diabetic Patient Following the COVID-19 Vaccination

BACKGROUND

A considerable number of COVID-19 vaccines became available following the outbreak. Yet, various inflammatory and autoimmune complications have been reported following vaccination. We aimed to report the case of a type 1 diabetic patient converting from Hashimoto's thyroiditis to Graves' disease after the fourth dose of COVID-19 vaccine, thought to trigger an autoimmune/inflammatory syndrome induced by adjuvants (ASIA syndrome).

CASE PRESENTATION

A thirty-one-year-old female patient with type 1 diabetes and Hashimoto's thyroiditis applied to our clinic with complaints of palpitations, anxiety, and weight loss one month after the fourth dose of COVID-19 vaccine (2 doses of CoronaVac + 2 doses of Pfizer/BioNTech). She was receiving levothyroxine 50 mcg/day. When her thyroid function tests showed thyrotoxicosis, we initially considered thyroxine-related exogenous thyrotoxicosis. However, we considered Graves' disease upon persisting thyrotoxicosis despite thyroxine withdrawal, positive serum TSH receptor antibody titers, and other imaging findings. Therefore, various autoimmune and inflammatory events have been reported after the COVID-19 vaccination. Adjuvants in vaccines can trigger autoimmune events, which lead to ASIA syndrome. COVID-19 vaccines may cause increased TSH receptor antibody levels or change the balance in the activity of blocking and stimulating antibodies, which may cause a conversion from Hashimoto's to Graves' disease.

CONCLUSION

This was the first case report where the patient experienced a conversion from Hashimoto's to Graves' disease after COVID-19 vaccination, which may ultimately be related to ASIA syndrome. Yet, more data is needed to elucidate such a relationship, and patients should closely be checked regularly after four doses of vaccination.

An overview of the hematological picture with antithyroid therapy in Graves' disease

Aim: Graves' disease is an autoimmune thyroid disease that is the most common cause of hyperthyroidism. Peripheral blood cell parameters such as neutrophils, lymphocytes, and platelets play a role in inflammation control. Several studies have proven that neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio and platelet-lymphocyte ratio are indicators of chronic subclinical inflammation in various diseases. In our study, we aimed to review the peripheral blood picture by evaluating these parameters before and after antithyroid treatment in patients with Graves' disease. Patients and methods: A total of 120 patients (93 female, 27 male) between the ages of 18-65 were included. Demographic data, hemogram and biochemical data of the patients were recorded retrospectively at the time of diagnosis and after euthyroidism was achieved with medical treatment. Results: During the treatment, there was an increase in hemoglobin, lymphocytes, neutrophils and red cell distribution width, while a decrease in monocytes was observed. There was no significant difference between white blood cell, platelet and mean platelet volume. In addition, while there was no statistically significant difference between neutrophil-lymphocyte ratio (p = 0.8) and thrombocyt-lymphocyte ratio (p = 0.078) after euthyroid state, a statistically significant difference was found in favor of a decrease in monocyte-lymphocyte ratio (p = 0.006). Conclusion: Changes in hematopoiesis are relatively common in patients with newly diagnosed Graves' disease, and initiation of antithyroid therapy leads to improvement in these parameters. Although neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio and platelet-lymphocyte ratio are accepted as new, non-invasive markers in clinical evaluation, in our study only a significant decrease in monocyte-lymphocyte ratio levels was observed after euthyroidism was achieved with antithyroid treatment.

Menstrual Changes after COVID-19 Infection and COVID-19 Vaccination

BACKGROUND

Several factors such as stress, depression, infection, and vaccination influenced the menstrual cycle in women during the coronavirus disease 2019 (COVID-19) pandemic. We investigated whether there were changes in the menstrual cycle in women after COVID-19 vaccination or infection and, if so, the nature of the change.

METHODS

This study was designed as a descriptive, cross-sectional study. A face-to-face survey was conducted among menstruating women aged 18-50 years from May 31 to July 31, 2022. Women were inquired about their first three menstrual cycles that occurred after COVID-19 infection or vaccination.

RESULTS

Of 241 women with COVID-19 infection, 86 (35.7%) mentioned that they experienced various changes in their menstrual patterns in the first three cycles after infection. Of 537 participants who received various COVID-19 vaccines, 82 (15.1%) stated that they experienced changes in their menstrual patterns after vaccination. The incidence of postvaccination menstrual change was higher in women who received Pfizer-BioNTech and Sinovac (CoronaVac) vaccines. Only 10.9% of women who reported a change in their menstrual pattern after vaccination or infection consulted a physician.

CONCLUSION

COVID-19 infection and vaccination can affect the menstrual cycle in women. It is important to be aware of the menstrual changes after COVID-19 infection and vaccination and to warn and inform women about this issue.

Long-Term Outcomes of Tamoxifen Citrate Therapy and Histo- and Immunopathological Properties in Riedel Thyroiditis

BACKGROUND

Riedel thyroiditis (RT) is a rare form of thyroiditis; thus, data about the disease course and treatment options are limited. Therefore, we aimed to assess the clinical, serological, radiological, and histopathological features, as well as short- and long-term follow-up of RT patients under glucocorticoid (GC) and tamoxifen citrate (TMX). Parameters related to IgG4-related diseases (IgG4-RD) were also investigated.

METHODS

Eight patients with RT diagnosed between 2000 and 2019 were enrolled. Data were collected in a retrospective and prospective manner. The diagnosis was confirmed with histopathological features in all patients. Results of the treatment with GCs on short- to mid-term, followed by TMX in the long term, were evaluated.

RESULTS

The mean age at diagnosis was 40.5 ± 6.8 years; female predominance was observed (F/M:7/1). Parameters related to IgG4-RD, like increase in IgG4 serum levels, total plasmablast counts, and IgG4+ plasmablasts, were negative in most of our patients in both active and inactive states of the disease. Likewise, an increased ratio of IgG4/IgG-positive plasma cells >40% could only be observed in 2 cases. GCs followed by TMX were given to the patients with an over-all median follow-up time of 67 (8-216) months. All the patients considerably improved clinically and had a reduction in the size of the mass lesion on GCs, followed by TMX therapy. None of the patients had a recurrence under TMX therapy for a median period of 18.5 (7-96) months.

CONCLUSION

Even though RT is suggested to be a member of IgG4-RD, serologic or histological evidence of IgG4 elevation or positivity is only useful for diagnosis and follow-up of RT. The diagnosis should be based on clinical and radiological evidence and confirmed by histopathology. GCs are effective for initial treatment, and TMX is a successful and safe therapeutic option for long-term maintenance therapy.