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Kuwano A, Nagasawa S, Koga Y, Tanaka K, Yada M, Masumoto A, Motomura K. Diagnostic features of autoimmune hepatitis in SARS‑CoV‑2‑vaccinated vs. unvaccinated individuals. Exp Ther Med 2024; 28:337. [PMID: 39006455 PMCID: PMC11240278 DOI: 10.3892/etm.2024.12626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/06/2024] [Indexed: 07/16/2024] Open
Abstract
The global coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has affected millions of lives, leading to significant morbidity and mortality. With >772 million cases and nearly seven million deaths reported worldwide to date, the development of vaccines has been a critical step in mitigating the impact of COVID-19. However, concerns have arisen regarding the potential for SARS-CoV-2 mRNA vaccination to trigger autoimmune diseases, including autoimmune hepatitis (AIH). The present single-center, retrospective study aimed to compare the clinical and pathological features of AIH in patients with or without a history of SARS-CoV-2 mRNA vaccination. A total of 72 patients with AIH were examined. Among them, 10 had received the SARS-CoV-2 mRNA vaccination prior to AIH onset. These patients exhibited more pronounced CD4+ T cell infiltration into the liver tissue compared with those who were unvaccinated. No significant differences in the levels of other liver enzymes, autoimmune antibodies, or CD8+ T cell infiltration were observed between the groups. Moreover, the AIH patients with a history of SARS-CoV-2 mRNA vaccination had more extensive CD4+ T cell infiltration in their liver tissues than the unvaccinated patients. These findings suggested that the immune response to SARS-CoV-2 mRNA vaccination may influence the pathogenesis of AIH, highlighting the need for further research into the relationship between SARS-CoV-2 mRNA vaccination and autoimmune liver diseases. Such studies will also help clarify the distinction between vaccine-induced liver injury and traditional AIH.
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Affiliation(s)
- Akifumi Kuwano
- Department of Hepatology, Aso Iizuka Hospital, Iizuka, Fukuoka 820-8505, Japan
| | - Shigehiro Nagasawa
- Department of Hepatology, Aso Iizuka Hospital, Iizuka, Fukuoka 820-8505, Japan
| | - Yuta Koga
- Department of Hepatology, Aso Iizuka Hospital, Iizuka, Fukuoka 820-8505, Japan
| | - Kosuke Tanaka
- Department of Hepatology, Aso Iizuka Hospital, Iizuka, Fukuoka 820-8505, Japan
| | - Masayoshi Yada
- Department of Hepatology, Aso Iizuka Hospital, Iizuka, Fukuoka 820-8505, Japan
| | - Akihide Masumoto
- Department of Hepatology, Aso Iizuka Hospital, Iizuka, Fukuoka 820-8505, Japan
| | - Kenta Motomura
- Department of Hepatology, Aso Iizuka Hospital, Iizuka, Fukuoka 820-8505, Japan
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2
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Medenica S, Stojanovic V, Capece U, Mazzilli R, Markovic M, Zamponi V, Vojinovic T, Migliaccio S, Defeudis G, Cinti F. The interlink between thyroid autoimmunity and type 1 diabetes and the impact on male and female fertility. Hormones (Athens) 2024; 23:429-437. [PMID: 38748060 DOI: 10.1007/s42000-024-00563-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/18/2024] [Indexed: 09/28/2024]
Abstract
The aim of this review is to discuss the several interconnections between thyroid autoimmunity and type 1 diabetes in terms of epidemiology, immunoserology, genetic predisposition, and pathogenic mechanisms. We will also analyze the impact of these conditions on both male and female fertility. A literature search was carried out using the MEDLINE/PubMed, Scopus, Google Scholar, ResearchGate, and Clinical Trials Registry databases with a combination of keywords. It was found that the prevalence of thyroid autoantibodies in individuals with type 1 diabetes (T1DM) varied in different countries and ethnic groups from 7 to 35% in both sexes. There are several types of autoantibodies responsible for the immunoserological presentation of autoimmune thyroid diseases (AITDs) which can be either stimulating or inhibiting, which results in AITD being in the plus phase (thyrotoxicosis) or the minus phase (hypothyroidism). Different types of immune cells such as T cells, B cells, natural killer (NK) cells, antigen presenting cells (APCs), and other innate immune cells participate in the damage of the beta cells of the islets of Langerhans, which inevitably leads to T1D. Multiple genetic and environmental factors found in variable combinations are involved in the pathogenesis of AITD and T1D. In conclusion, although it is now well-known that both diabetes and thyroid diseases can affect fertility, only a few data are available on possible effects of autoimmune conditions. Recent findings nevertheless point to the importance of screening patients with immunologic infertility for AITDs and T1D, and vice versa.
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Affiliation(s)
- Sanja Medenica
- Department of Endocrinology, Internal Medicine Clinic, Clinical Center of Montenegro, Faculty of Medicine, University of Montenegro, Podgorica, Montenegro
| | - Vukasin Stojanovic
- Emergency Medicine Center of Montenegro, Faculty of Medicine, University of Montenegro, Podgorica, Montenegro
| | - Umberto Capece
- UOS Centro Malattie Endocrine e Metaboliche, UOC Endocrinologia e Diabetologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rossella Mazzilli
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant' Andrea Hospital, Rome, Italy
| | - Milica Markovic
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Virginia Zamponi
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant' Andrea Hospital, Rome, Italy
| | - Tanja Vojinovic
- Faculty of Medicine, University od Montenegro, Podgorica, Montenegro
| | - Silvia Migliaccio
- Department of Movement, Human and Health Sciences, University Foro Italico of Rome, Rome, 00135, Italy
- Unit of Endocrinology and Diabetes, Department of Medicine, University Campus Bio-Medico di Roma, Rome, Italy
| | - Giuseppe Defeudis
- Department of Movement, Human and Health Sciences, University Foro Italico of Rome, Rome, 00135, Italy.
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
- Unit of Endocrinology and Diabetes, Department of Medicine, University Campus Bio-Medico di Roma, Rome, Italy.
| | - Francesca Cinti
- UOS Centro Malattie Endocrine e Metaboliche, UOC Endocrinologia e Diabetologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
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3
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Alunno A, Carubbi F, Tan AL, Sen P, Cavagna L, Joshi M, Day J, Saha S, Gutiérrez CET, Caballero-Uribe CV, Distler O, Chinoy H, Aggarwal R, Agarwal V, Gupta L. COVID-19 severity, breakthrough infections and vaccine safety in young individuals with autoimmune diseases: insights from the COVAD study. Rheumatol Int 2024; 44:1725-1731. [PMID: 39003346 PMCID: PMC11343807 DOI: 10.1007/s00296-024-05654-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/21/2024] [Indexed: 07/15/2024]
Abstract
Notwithstanding the wealth of literature on COVID-19, studies focusing on young adults with autoimmune diseases (AD) are lacking. To determine early (within 7 days) and late (after 7 days) anti-SARS-CoV-2 vaccine-related adverse events (AEs), post-vaccine disease flares, COVID-19 severity and breakthrough infections (B-INFs) in young people with rheumatic diseases (RMDs) and non-rheumatic autoimmune diseases (nr-ADs) compared to healthy controls (HC). Data were captured through the international COVID-19 vaccination in autoimmune diseases (COVAD) 1 and 2 questionnaires. Of 20,685 complete responses, we identified 6010 from patients aged 18-35 years (1692 RMD, 400 nrADs, 3918 HC) who received up to 4 vaccine doses. BNT162b2 was the most frequently administered vaccine and prior to vaccination, 7% of people with nrAD were taking immunosuppressants (IS) versus 80% in RMDs. Early mild AEs were more frequent in RMDs (93%) and nr-ADs (92%) compared to HC (85%). The frequency of late mild AEs was < 20% in all groups. Severe AEs were rare. SARS-CoV-2 infection rates were similar across all groups, however, RMD patients reported a single episode of infection more frequently than nrADs and HC, while nrADs reported multiple infections more frequently than RMD. Self-reported disease flares were reported by 10% or RMD and 7% of nrAD patients. Our study reinforces the safety of anti-SARS-CoV-2 vaccine also in young people with ADs, but it also highlights that among young individuals the number and clinical picture of SARS-CoV-2 infections is affected more by the type of AD rather than by coexisting IS therapy.
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Affiliation(s)
- Alessia Alunno
- Internal Medicine and Nephrology Division, Department of Clinical Medicine, Life, Health and Environmental Sciences, University of L'Aquila and San Salvatore Hospital, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy.
| | - Francesco Carubbi
- Internal Medicine and Nephrology Division, Department of Clinical Medicine, Life, Health and Environmental Sciences, University of L'Aquila and San Salvatore Hospital, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy
| | - Ai Lyn Tan
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Parikshit Sen
- Maulana Azad Medical College, 2-Bahadurshah Zafar Marg, New Delhi, Delhi, 110002, India
| | - Lorenzo Cavagna
- Rheumatology Unit, Dipartimento di Medicine Interna e Terapia Medica, Università degli Studi di Pavia, Pavia, Lombardy, Italy
| | - Mrudula Joshi
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospitals, Pune, India
| | - Jessica Day
- Department of Rheumatology, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
- Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Sreoshy Saha
- Mymensingh Medical College, Mymensingh, Bangladesh
| | - Carlos Enrique Toro Gutiérrez
- Reference Center for Osteoporosis, Rheumatology and Dermatology, Pontifica Universidad Javeriana Cali, Cali, Colombia
| | | | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hector Chinoy
- Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- National Institute for Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, The University of Manchester, Manchester, UK
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Rohit Aggarwal
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Latika Gupta
- Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Department of Rheumatology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
- Department of Rheumatology, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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4
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Shen Y, Zhang Y, Xu YY, Li X, Wu J, Pei H, Wang L, Zhu T. Causal associations between severe COVID-19 and diseases of seven organs: a proteome-wide mendelian randomization study. Front Genet 2024; 15:1421824. [PMID: 39192889 PMCID: PMC11347274 DOI: 10.3389/fgene.2024.1421824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 07/29/2024] [Indexed: 08/29/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic poses an enormous threat to public health worldwide. Many retrospective studies and case reports to date have shown associations between severe COVID-19 and diseases of multi-organs. However, the research on the causal mechanisms behind this phenomenon is neither extensive nor comprehensive. We conducted a proteome-wide Mendelian randomization (MR) study using summary statistics from a Genome-Wide Association Studies (GWAS) of severe COVID-19 and diseases related to seven organs: lung, spleen, liver, heart, kidney, testis, and thyroid, based on the European ancestry. The primary analytical method used is the radial inverse variance-weighted (radial IVW) method, supplemented with the inverse variance-weighted (IVW), weighted-median (WM), MR-Egger methods. Our findings have confirmed the association between severe COVID-19 and multiple organ-related diseases, such as Hypothyroidism, strict autoimmune (HTCBSA), Thyroid disorders (TD), and Graves' disease (GD). And we have also identified certain proteins that are associated with organ-related diseases, such as Superoxide Dismutase 2 (SOD2) and TEK Receptor Tyrosine Kinase (TEK), which are also considered potential drug targets. Phenotype scanning and sensitivity analyses were implemented to consolidate the results for Mendelian randomization. This study provides a compelling foundation for investigating COVID-19 caused diseases in future studies.
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Affiliation(s)
- Yunhan Shen
- College of Mathematics and Computer Science, Zhejiang A&F University, Hangzhou, China
| | - Yi Zhang
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Ye-yang Xu
- Songyang County People’s Hospital, Lishui, Zhejiang, China
| | - Xinyi Li
- College of Mathematics and Computer Science, Zhejiang A&F University, Hangzhou, China
| | - Jiachen Wu
- College of Mathematics and Computer Science, Zhejiang A&F University, Hangzhou, China
| | - Hao Pei
- MobiDrop (Zhejiang) Co., Ltd., Tongxiang, Zhejiang, China
| | - Linyan Wang
- Zhejiang Provincial Key Laboratory of Ophthalmology, Eye Center, The Second Affiliated Hospital, School of Medicine, Zhejiang Provincial Clinical Research Center for Eye Diseases, Zhejiang Provincial Engineering Institute on Eye Diseases, Zhejiang University, Hangzhou, Zhejiang, China
| | - Tiansheng Zhu
- College of Mathematics and Computer Science, Zhejiang A&F University, Hangzhou, China
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Al-Abdulrazzaq D, Albatineh AN, Khalifa D, Alrefae A, Al-Awadhi E, Alkandari A, Alhomaidah D, Cunningham SA, Al-Kandari H. Prevalence and factors associated with thyroid autoimmunity among children newly diagnosed with type 1 diabetes before and during the COVID-19 pandemic: Evidence from Kuwait. Diabetes Metab Res Rev 2024; 40:e3824. [PMID: 38837532 DOI: 10.1002/dmrr.3824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/06/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
AIMS This study reports the prevalence and characteristics related to the development of thyroid autoimmunity among children newly diagnosed with type I diabetes (T1D) during the COVID-19 pandemic in Kuwait. MATERIALS AND METHODS This is a prospective observational study of all children under age 14 years newly diagnosed with T1D in Kuwait. We define the duration of the COVID-19 pandemic from the official declaration of the first identified positive COVID-19 case on 24 February 2020 until 31 December 2022. For comparison, we use the time period directly before the COVID-19 pandemic, 1 January 2017 to 23 February 2020. RESULTS One thousand twenty-four (1024) children newly diagnosed with T1D in Kuwait during the study period were included. Among newly diagnosed children, 20.3% tested positive for thyroid antibodies during the COVID-19 pandemic, compared with 14.5% during the pre-pandemic period (p = 0.015). Children with positive COVID-19 status were more likely to present with thyroid antibodies (p = 0.035). After adjusting for other characteristics, patients diagnosed with T1D during the COVID-19 pandemic had double the odds of testing positive for thyroid antibodies (Adjusted odds ratio = 2.173, 95%CI: 1.108, 4.261, p = 0.024). CONCLUSIONS Incident cases of T1D during the COVID-19 pandemic may be different in aetiology or contextual factors leading to a higher risk of thyroid autoimmunity. Longitudinal studies are needed to understand the role of COVID-19 in the onset and progression of T1D and on thyroid autoimmunity and disease.
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Affiliation(s)
- Dalia Al-Abdulrazzaq
- Department of Pediatrics, College of Medicine, Kuwait University, Safat, Kuwait
- Department of Population Health, Dasman Diabetes Institute, Kuwait City, Kuwait
- Ministry of Health, Kuwait City, Kuwait
| | - Ahmed Najeeb Albatineh
- Department of Community Medicine and Behavioral Sciences, College of Medicine, Kuwait University, Safat, Kuwait
| | - Doaa Khalifa
- Department of Population Health, Dasman Diabetes Institute, Kuwait City, Kuwait
- Ministry of Health, Kuwait City, Kuwait
| | - Anwaar Alrefae
- Department of Population Health, Dasman Diabetes Institute, Kuwait City, Kuwait
| | | | - Abdullah Alkandari
- Department of Population Health, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Doha Alhomaidah
- Department of Population Health, Dasman Diabetes Institute, Kuwait City, Kuwait
- Ministry of Health, Kuwait City, Kuwait
| | | | - Hessa Al-Kandari
- Department of Population Health, Dasman Diabetes Institute, Kuwait City, Kuwait
- Ministry of Health, Kuwait City, Kuwait
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6
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d'Aniello F, Amodeo ME, Grossi A, Ubertini G. Thyroiditis and COVID-19: focus on pediatric age. A narrative review. J Endocrinol Invest 2024; 47:1633-1640. [PMID: 38457058 DOI: 10.1007/s40618-024-02331-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/03/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE In light of the growing concern over the possible link between SARS-CoV2 infection and autoimmune diseases, we conducted a review to investigate the impact of the pandemic outbreak on thyroid diseases. METHODS We carried out a narrative review of all pediatric cases described in the literature, mainly focusing on the possible association of COVID-19 with the incidence of autoimmune and post-infective thyroid diseases (namely Hashimoto's Thyroiditis (HT), Grave's Disease (GD) and Sub-Acute Thyroiditis (SAT)). We also felt it was necessary to provide a brief review of Non-thyroidal Illness Syndrome (NTIS) and Multisystem Inflammatory Syndrome in Children (MIS-C) because of their overlap with thyroiditis. RESULTS There is currently no conclusive evidence linking SARS-CoV-2 infection with an increased incidence of autoimmune thyroiditis (AT) in pediatric age. However, SAT may be a mild complication of SARS-CoV-2 infection, as is the case with other viral infections. SAT typically resolves on its own and does not require treatment. NTIS may be associated with inflammatory complications, such as MIS-C, and admission to intensive care. It may also be considered a prognostic risk factor for severe disease. The hypothesized pathogenetic mechanisms of thyroid damage in COVID-19 include direct damage due to the significant expression of angiotensin-converting enzyme 2 (ACE2) in the thyroid gland, which is a ligand for the virus, and indirect damage due to immune dysregulation, such as the overproduction of IL-6, which is thought to be part of the pathogenesis of thyroiditis. CONCLUSION However, due to the limited evidence available, further prospective longitudinal studies are required to clarify the relationship between COVID-19 and thyroid disease in children and adolescents, as well as to investigate any potential long-term consequences.
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Affiliation(s)
- F d'Aniello
- Endocrinology and Diabetology Unit, IRCCS 'Bambino Gesù' Children's Hospital, Rome, Italy.
- School of Pediatrics, University of Rome Tor Vergata, Rome, Italy.
| | - M E Amodeo
- Endocrinology and Diabetology Unit, IRCCS 'Bambino Gesù' Children's Hospital, Rome, Italy
- School of Pediatrics, University of Rome Tor Vergata, Rome, Italy
| | - A Grossi
- Endocrinology and Diabetology Unit, IRCCS 'Bambino Gesù' Children's Hospital, Rome, Italy
| | - G Ubertini
- Endocrinology and Diabetology Unit, IRCCS 'Bambino Gesù' Children's Hospital, Rome, Italy
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Sakai K, Yonaha T, Shinzato T, Taira T. Subacute Thyroiditis Following COVID-19: A Case of Diagnostic Challenge in the Absence of Neck Pain. Cureus 2024; 16:e62203. [PMID: 39006627 PMCID: PMC11240006 DOI: 10.7759/cureus.62203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 07/16/2024] Open
Abstract
This case report presents a 77-year-old woman who developed subacute thyroiditis following COVID-19. The patient exhibited atypical symptoms, including fever, fatigue, anorexia, significant weight loss, headaches, and palpitations, without the typical neck pain or tenderness associated with thyroiditis. One week later, a follow-up examination showed mild enlargement and tenderness of the thyroid. Laboratory tests indicated elevated thyroid hormone levels and suppressed thyroid-stimulating hormone. Ultrasonography revealed diffuse thyroid enlargement with poor blood flow, consistent with subacute thyroiditis. Despite the absence of typical neck pain, the diagnosis was supported by clinical, laboratory, and imaging findings. This case suggests the importance of considering subacute thyroiditis as a potential secondary condition following COVID-19, even in the absence of typical symptoms. Clinicians should consider that and perform thorough evaluations in patients with recent COVID-19 exposure and nonspecific symptoms.
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Affiliation(s)
- Kan Sakai
- General Internal Medicine, Nakagami Hospital, Okinawa, JPN
| | | | | | - Takahiro Taira
- General Internal Medicine, Nakagami Hospital, Okinawa, JPN
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Starnes LS, Starnes JR, Ghafuri D, Charnogursky C, Duffus S, Fritz C. Fever and Neck Pain in an Adolescent: A Case Report. Clin Pediatr (Phila) 2024; 63:560-563. [PMID: 37249249 PMCID: PMC11017687 DOI: 10.1177/00099228231176704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Lauren S. Starnes
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Joseph R. Starnes
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Djamila Ghafuri
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Cara Charnogursky
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Sara Duffus
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Cristin Fritz
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
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9
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Deng L, Zhang Y, Sun H. Apathetic Graves' disease with severe hepatic and renal dysfunction induced by COVID-19 infection: Case report and literature review. Medicine (Baltimore) 2024; 103:e37456. [PMID: 38489722 PMCID: PMC10939614 DOI: 10.1097/md.0000000000037456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/12/2024] [Indexed: 03/17/2024] Open
Abstract
RATIONALE A rare and intractable case of apathetic Graves' disease (GD) with severe liver and kidney damage induced by coronavirus disease 2019 (COVID-19) carries a certain risk of missing diagnosis and delayed treatment during the COVID-19 pandemic. PATIENT CONCERN A 60-year-old female patient developed anorexia, exhaustion, jaundice, nausea, and vomiting 10 days after COVID-19 infection. She was admitted to the Infectious Diseases Department because of recurring symptoms for more than a month. DIAGNOSIS Based on the patient's epidemiological history, clinical symptoms, and prior history, she was preliminarily diagnosed with GD induced by COVID-19 with severe hyperthyroid-related liver injury and chronic kidney disease stage 4. Drug-induced and radiation-induced liver injuries occurred sequentially throughout the therapy. INTERVENTION Methimazole (MMI) (10 mg/d) was administered for 1 week, and the patient's symptoms, thyroid function, and liver and kidney function improved. Nevertheless, the aforementioned symptoms and liver and kidney function deteriorated 20 days after increasing the MMI dose (20 mg/d). Therefore, in the presence of an artificial liver, hemodialysis, and other medical conditions, the treatment schedule was adjusted to individualized 131I anti-hyperthyroidism therapy. OUTCOME After 131I treatment, the patient's liver function returned to almost normal levels after a month, but worsened when the hepatoprotective drugs were stopped. Renal function did not deteriorate significantly and returned to baseline after 3 months. Thyroid function was restored to normal approximately 4 months later. CONCLUSION COVID-19 may induce GD. Multidisciplinary collaboration can be initiated as early as possible. Individualized 131I therapy or long-term low-dose MMI (10 mg/d) can be considered to manage hyperthyroidism in GD patients with liver and kidney dysfunction and to prolong liver protection therapy appropriately.
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Affiliation(s)
- Liting Deng
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong, People’s Republic of China
| | - Yingtong Zhang
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong, People’s Republic of China
| | - Huilin Sun
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong, People’s Republic of China
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10
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Yang S, Guan T, Yang H, Hu Y, Zhao Y. Case report: Neglected subacute thyroiditis: a case following COVID-19 vaccination. Front Med (Lausanne) 2024; 11:1349615. [PMID: 38523906 PMCID: PMC10957742 DOI: 10.3389/fmed.2024.1349615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
We report a case of overlooked Subacute Thyroiditis (SAT) potentially induced by the administration of a COVID-19 vaccine. This case prompted a thorough review of the existing literature to elucidate possible mechanisms by which immune responses to the COVID-19 vaccine might precipitate thyroid damage. The primary objective is to enhance the clinical understanding and awareness of SAT among healthcare professionals. Subacute thyroiditis is a prevalent form of self-limiting thyroid disorder characterized by fever, neck pain or tenderness, and palpitations subsequent to viral infection. The development of numerous SARS-CoV-2 vaccines during the COVID-19 pandemic was intended to mitigate the spread of the virus. Nevertheless, there have been documented instances of adverse reactions arising from SARS-CoV-2 vaccines, such as the infrequent occurrence of subacute thyroiditis. While the majority of medical practitioners can discern classic subacute thyroiditis, not all cases exhibit typical characteristics, and not all systematic treatments yield positive responses. In this study, we present a rare case of subacute thyroiditis linked to the administration of the SARS-CoV-2 vaccine. A previously healthy middle-aged female developed fever and sore throat 72 h post-inoculation with the inactivated SARS-CoV-2 vaccine. Initially attributing these symptoms to a common cold, she self-administered ibuprofen, which normalized her body temperature but failed to alleviate persistent sore throat. Suspecting a laryngopharyngeal disorder, she sought treatment from an otolaryngologist. However, the pain persisted, accompanied by intermittent fever over several days. After an endocrinology consultation, despite the absence of typical neck pain, her examination revealed abnormal thyroid function, normal thyroid antibodies, heterogeneous echogenicity on thyroid ultrasonography, and elevated levels of Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP). These findings led to a consideration of the diagnosis of SAT. Initially, she was treated with non-steroidal anti-inflammatory drugs (NSAIDs) for her fever, which proved effective, but her neck pain remained uncontrolled. This suggested a poor response to NSAIDs. Consequently, steroid therapy was initiated, after which her symptoms of fever and neck pain rapidly resolved.
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Affiliation(s)
- Shuai Yang
- School of Sports Medicine and Health, Chengdu Sport University, Chengdu, China
- Department of Endocrinology and Metabolism, West Chengdu Hospital, Chengdu, China
| | - Ting Guan
- School of Sports Medicine and Health, Chengdu Sport University, Chengdu, China
| | - HuanYi Yang
- School of Sports Medicine and Health, Chengdu Sport University, Chengdu, China
| | - YiRong Hu
- Department of Endocrinology and Metabolism, West Chengdu Hospital, Chengdu, China
| | - Yan Zhao
- School of Sports Medicine and Health, Chengdu Sport University, Chengdu, China
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11
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Nowaczewska M, Straburzyński M, Meder G, Waliszewska-Prosół M. The relationship between migraine and Hashimoto's thyroiditis: a single center experience. Front Neurol 2024; 15:1370530. [PMID: 38426168 PMCID: PMC10902007 DOI: 10.3389/fneur.2024.1370530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 02/05/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Hashimoto's thyroiditis (HT) is nowadays the leading cause of hypothyroidism with high and still growing prevalence in general population, but there are lack of data regarding migraine and HT connection. Methods The aim of this study was to analyze the prevalence of HT in migraine and to check if the presence of HT influence migraine severity. This retrospective observational cohort study involved consecutive migraine patients consulted at our Headache Center with diagnosis of migraine. Electronic charts of patients were collected, including data on migraine type, presence of cranial autonomic symptoms (CAS), monthly migraine days (MMD), medication overuse headache (MOH), and the presence of comorbidities including HT. Results We found 928 eligible migraine patients, 88.7% were women. The mean age was 36.09 years. 592 (63.8%) were diagnosed with episodic migraine (EM), the rest with chronic migraine (CM). MOH was additionally diagnosed in 258 (27.8%) patients. The duration of migraine was 15.99 years. 106 (11.4%) was diagnosed with HT, 148 (15.9%) with hypothyroidisms, while 84 (9.05%) had both diagnosis. Migraine patients with HT were significantly older (p < 0.001), were more frequently women (p = 0.0017), had longer duration of migraine (p < 0.001), had CAS more frequently (<0.001), developed CM (p = 0.0169) and depression more frequently (p = 0.0047) and had more MMD (p = 0.0195) as compared with individuals without HT. According to our multivariate logistic model, the presence CM was positively associated with HT (OR 1.76, p = 0.045), MOH and duration of migraine, while negatively associated with aura. Conclusion HT is very prevalent in migraine patients. This is the first study considering migraine and HT to be comorbid and suggesting that HT may influence the course of migraine causing its chronification.
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Affiliation(s)
- Magdalena Nowaczewska
- Athleticomed—Pain and Sport Injury Center with Headache and Migraine Treatment Division, Bydgoszcz, Poland
- Department of Otolaryngology, Head and Neck Surgery, and Laryngological Oncology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Marcin Straburzyński
- Department of Family Medicine and Infectious Diseases, University of Warmia and Mazury, Olsztyn, Poland
| | - Grzegorz Meder
- Department of Interventional Radiology, Jan Biziel University Hospital, Bydgoszcz, Poland
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12
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Du SN, Chen JW, Li W, Wang MC, Mao YS. Development of autoimmune thyroid disease after COVID-19 infection: case report. Front Med (Lausanne) 2024; 11:1303855. [PMID: 38384412 PMCID: PMC10879344 DOI: 10.3389/fmed.2024.1303855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/26/2024] [Indexed: 02/23/2024] Open
Abstract
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.
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Affiliation(s)
- Si-na Du
- Department of Endocrinology, Cixi People Hospital Medical Health Group (Cixi People Hospital), Cixi, China
| | - Jian-wei Chen
- Department of Endocrinology, Cixi People Hospital Medical Health Group (Cixi People Hospital), Cixi, China
| | - Wei Li
- Department of Endocrinology, The Affiliated Lihuili Hospital of Ningbo University, Ningbo, China
| | - Meng-chuan Wang
- Department of Endocrinology, Cixi People Hospital Medical Health Group (Cixi People Hospital), Cixi, China
| | - Yu-shan Mao
- Department of Endocrinology, The first Affiliated Hospital of Ningbo University, Ningbo, China
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13
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Álvarez Pérez LF, Vila S. Exacerbation of Behcet's Disease and Pyoderma Gangrenosum Following COVID-19 Infection: A Case Report. Cureus 2023; 15:e49386. [PMID: 38146565 PMCID: PMC10749583 DOI: 10.7759/cureus.49386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2023] [Indexed: 12/27/2023] Open
Abstract
Behcet's disease (BD) and pyoderma gangrenosum (PG) are rare autoimmune inflammatory diseases that have been reported to relapse following COVID-19 infection. BD is a multisystemic syndrome that may involve multiple body organs. PG is a skin disease that can be a part of the skin involvement of BD. We report a 33-year-old woman with BD and PG who developed headaches, arthralgias, and rapidly progressive painful skin ulcers after COVID-19. She had not complained about BD or PG symptoms for two years prior to admission. Treatment at admission comprised infliximab 560 mg every eight weeks, azathioprine 50 mg daily, and low-dose aspirin. Due to the suspicion of neuro BD and the rapid appearance and progression of the ulcers, she was treated with intravenous (IV) methylprednisolone 1000 mg daily three times followed by prednisone at 1 mg/kg/day. Azathioprine was increased to 100 mg bid. Local ulcer care was provided. She was discharged home on the eighth hospital day. The arthralgias were completely gone, and the headaches and skin ulcers had improved. Six months after discharge, she was off prednisone and continued infliximab and azathioprine. She had no headaches or joint pains, and the ulcers had completely healed. One year after admission, BD and PG signs and symptoms had completely disappeared. This case highlights the importance of recognizing that autoimmune diseases may exacerbate COVID-19. Timely management is crucial to prevent complications and morbidity. To our knowledge, this is a rare case report describing BD and PG exacerbation following COVID-19.
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Affiliation(s)
- Luis F Álvarez Pérez
- Department of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI
| | - Salvador Vila
- Department of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI
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14
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Stathi D, Triantafyllidis KK, Zafeiri M, Karalliedde J, Kechagias KS. COVID-19 induced type 1 diabetes: A systematic review of case reports and series. J Int Med Res 2023; 51:3000605231210403. [PMID: 37940619 PMCID: PMC10637179 DOI: 10.1177/03000605231210403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/11/2023] [Indexed: 11/10/2023] Open
Abstract
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.
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Affiliation(s)
- Dimitra Stathi
- Department of Endocrinology and Diabetes, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Marina Zafeiri
- School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
| | - Janaka Karalliedde
- Department of Endocrinology and Diabetes, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Konstantinos S. Kechagias
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, UK
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15
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Vamshidhar IS, Rani SSS, Kalpana M, Gaur A, Umesh M, Ganji V, Saluja R, Taranikanti M, John NA. Impact of COVID-19 on thyroid gland functions with reference to Graves' disease: A systematic review. J Family Med Prim Care 2023; 12:1784-1789. [PMID: 38024874 PMCID: PMC10657079 DOI: 10.4103/jfmpc.jfmpc_2246_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/24/2023] [Accepted: 03/03/2023] [Indexed: 12/01/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is caused due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Both immediate and long-term adverse effects arise out of this disease's aftermath. It involves various organs, which include endocrine glands, nervous system, musculoskeletal system, and other organs. The long-term outcomes of the SARS-CoV-2 infection are influenced by preexisting comorbidities. Genetic, environmental, and immunological factors contribute to the development of various autoimmune diseases, which include Graves' disease (GD). The growing mystery surrounding this virus is exacerbated by auto-inflammatory diseases, such as pediatric inflammatory multisystemic syndrome (PIMS) or multisystem inflammatory syndrome in children (MIS-C), which raises concerns about the nature of the virus' connection to the autoimmune and auto-inflammatory sequelae. There is a need to understand the underlying mechanisms of developing GD in post-COVID-19 patients. There are limited data regarding the pathogenesis involved in post-COVID-19 GD. Our goal was to understand the various mechanisms involved in post-COVID-19 GD among patients with confirmed COVID-19 infection. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for 2020, a literature search of medical databases (PubMed, Cochrane Central Register of Controlled Trials, and Scopus) from February 2021 to February 2022 was performed by five authors. The keywords used were "Post COVID-19," "Grave's disease," "Cytokine storm," "Autoimmunity," and "Molecular mimicry." This review revealed three underlying mechanisms that resulted in post-COVID GD, which included cytokine storm, molecular mimicry, ACE2 receptor concentration, and cell-mediated immunity. The full spectrum of the effects of COVID-19 needs to be researched.
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Affiliation(s)
- I. S. Vamshidhar
- Department of Physiology, Government Medical College, Mahabubabad, Telangana, India
| | - S. S. Sabitha Rani
- Department of Pathology, Government Medical College, Bhadradri Kothagudem, Telangana, India
| | - Medala Kalpana
- Department of Physiology, AIIMS Bibinagar, Telangana, India
| | - Archana Gaur
- Department of Physiology, AIIMS Bibinagar, Telangana, India
| | | | - Vidya Ganji
- Department of Physiology, AIIMS Bibinagar, Telangana, India
| | - Rohit Saluja
- Department of Biochemistry, AIIMS Bibinagar, Telangana, India
| | | | - Nitin A. John
- Department of Physiology, AIIMS Bibinagar, Telangana, India
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16
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Peng K, Li X, Yang D, Chan SC, Zhou J, Wan EY, Chui CS, Lai FT, Wong CK, Chan EW, Leung WK, Lau CS, Wong IC. Risk of autoimmune diseases following COVID-19 and the potential protective effect from vaccination: a population-based cohort study. EClinicalMedicine 2023; 63:102154. [PMID: 37637754 PMCID: PMC10458663 DOI: 10.1016/j.eclinm.2023.102154] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Background Case reports suggest that SARS-CoV-2 infection could lead to immune dysregulation and trigger autoimmunity while COVID-19 vaccination is effective against severe COVID-19 outcomes. We aim to examine the association between COVID-19 and development of autoimmune diseases (ADs), and the potential protective effect of COVID-19 vaccination on such an association. Methods A retrospective cohort study was conducted in Hong Kong between 1 April 2020 and 15 November 2022. COVID-19 was confirmed by positive polymerase chain reaction or rapid antigen test. Cox proportional hazard regression with inverse probability of treatment weighting was applied to estimate the risk of incident ADs following COVID-19. COVID-19 vaccinated population was compared against COVID-19 unvaccinated population to examine the protective effect of COVID-19 vaccination on new ADs. Findings The study included 1,028,721 COVID-19 and 3,168,467 non-COVID individuals. Compared with non-COVID controls, patients with COVID-19 presented an increased risk of developing pernicious anaemia [adjusted Hazard Ratio (aHR): 1.72; 95% Confidence Interval (CI): 1.12-2.64]; spondyloarthritis [aHR: 1.32 (95% CI: 1.03-1.69)]; rheumatoid arthritis [aHR: 1.29 (95% CI: 1.09-1.54)]; other autoimmune arthritis [aHR: 1.43 (95% CI: 1.33-1.54)]; psoriasis [aHR: 1.42 (95% CI: 1.13-1.78)]; pemphigoid [aHR: 2.39 (95% CI: 1.83-3.11)]; Graves' disease [aHR: 1.30 (95% CI: 1.10-1.54)]; anti-phospholipid antibody syndrome [aHR: 2.12 (95% CI: 1.47-3.05)]; immune mediated thrombocytopenia [aHR: 2.1 (95% CI: 1.82-2.43)]; multiple sclerosis [aHR: 2.66 (95% CI: 1.17-6.05)]; vasculitis [aHR: 1.46 (95% CI: 1.04-2.04)]. Among COVID-19 patients, completion of two doses of COVID-19 vaccine shows a decreased risk of pemphigoid, Graves' disease, anti-phospholipid antibody syndrome, immune-mediated thrombocytopenia, systemic lupus erythematosus and other autoimmune arthritis. Interpretation Our findings suggested that COVID-19 is associated with an increased risk of developing various ADs and the risk could be attenuated by COVID-19 vaccination. Future studies investigating pathology and mechanisms would be valuable to interpreting our findings. Funding Supported by RGC Collaborative Research Fund (C7154-20GF).
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Affiliation(s)
- Kuan Peng
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Xue Li
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong SAR, China
| | - Deliang Yang
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Shirley C.W. Chan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Jiayi Zhou
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Eric Y.F. Wan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong SAR, China
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Celine S.L. Chui
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong SAR, China
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Francisco T.T. Lai
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong SAR, China
| | - Carlos K.H. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong SAR, China
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Esther W.Y. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong SAR, China
| | - Wai Keung Leung
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Chak-Sing Lau
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ian C.K. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science Park, Hong Kong SAR, China
- Aston Pharmacy School, Aston University, Birmingham, B4 7ET, UK
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17
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Mohammadi B, Dua K, Saghafi M, Singh SK, Heydarifard Z, Zandi M. COVID-19-induced autoimmune thyroiditis: Exploring molecular mechanisms. J Med Virol 2023; 95:e29001. [PMID: 37515444 DOI: 10.1002/jmv.29001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/30/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023]
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) damages multiple organs, including the thyroid, by direct invasion and cell entry via angiotensin-converting enzyme 2 or indirectly by promoting excessive inflammation in the body. The immune system is a critical factor in antiviral immunity and disease progression. In the context of SARS-CoV-2 infection, the immune system may become overly activated, resulting in a shift from regulatory to effector responses, which may subsequently promote the development and progression of autoimmune diseases. The incidence of autoimmune thyroid diseases, such as subacute thyroiditis, Graves' disease, and Hashimoto's thyroiditis, increases in individuals with COVID-19 infection. This phenomenon may be attributed to aberrant responses of T-cell subtypes, the presence of autoantibodies, impaired regulatory cell function, and excessive production of inflammatory cytokines, namely interleukin (IL)-6, IL-1β, interferon-γ, and tumor necrosis factor-α. Therefore, insights into the immune responses involved in the development of autoimmune thyroid disease according to COVID-19 can help identify potential therapeutic approaches and guide the development of effective interventions to alleviate patients' symptoms.
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Affiliation(s)
- Bita Mohammadi
- Department of Immunology, Mashhad University of Medical Sciences, Mashhad, Iran
- Innovated Medical Research Center, Mashhad Branch, Islamic Azad University, Mashhad, Iran
| | - Kamal Dua
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, NSW, Australia
- Faculty of Health, Australian Research Center in Complementary & Integrative Medicine, University of Technology Sydney, Ultimo, NSW, Australia
- Uttaranchal Institute of Pharmaceutical Sciences, Uttaranchal University, Dehradun, India
| | - Mohammadreza Saghafi
- Department of Immunology, Mashhad University of Medical Sciences, Mashhad, Iran
- Innovated Medical Research Center, Mashhad Branch, Islamic Azad University, Mashhad, Iran
| | - Sachin Kumar Singh
- Faculty of Health, Australian Research Center in Complementary & Integrative Medicine, University of Technology Sydney, Ultimo, NSW, Australia
- School of Pharmaceutical Sciences, Lovely Professional University, Punjab, India
| | - Zahra Heydarifard
- Department of Virology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
- School of Medicine, Hepatitis Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Milad Zandi
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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18
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Wilson GN. A Clinical Qualification Protocol Highlights Overlapping Genomic Influences and Neuro-Autonomic Mechanisms in Ehlers-Danlos and Long COVID-19 Syndromes. Curr Issues Mol Biol 2023; 45:6003-6023. [PMID: 37504295 PMCID: PMC10378515 DOI: 10.3390/cimb45070379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023] Open
Abstract
A substantial fraction of the 15% with double-jointedness or hypermobility have the traditionally ascertained joint-skeletal, cutaneous, and cardiovascular symptoms of connective tissue dysplasia and its particular manifestation as Ehlers-Danlos syndrome (EDS). The holistic ascertainment of 120 findings in 1261 EDS patients added neuro-autonomic symptoms like headaches, muscle weakness, brain fog, chronic fatigue, dyspnea, and bowel irregularity to those of arthralgia and skin laxity, 15 of these symptoms shared with those of post-infectious SARS-CoV-2 (long COVID-19). Underlying articulo-autonomic mechanisms guided a clinical qualification protocol that qualified DNA variants in 317 genes as having diagnostic utility for EDS, six of them identical (F2-LIFR-NLRP3-STAT1-T1CAM1-TNFRSF13B) and eighteen similar to those modifying COVID-19 severity/EDS, including ADAMTS13/ADAMTS2-C3/C1R-IKBKG/IKBKAP-PIK3C3/PIK3R1-POLD4/POLG-TMPRSS2/TMPRSS6-WNT3/WNT10A. Also, contributing to EDS and COVID-19 severity were forty and three genes, respectively, impacting mitochondrial functions as well as parts of an overlapping gene network, or entome, that are hypothesized to mediate the cognitive-behavioral, neuro-autonomic, and immune-inflammatory alterations of connective tissue in these conditions. The further characterization of long COVID-19 natural history and genetic predisposition will be necessary before these parallels to EDS can be carefully delineated and translated into therapies.
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Affiliation(s)
- Golder N Wilson
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, and KinderGenome Genetics Private Practice, 5347 W Mockingbird, Dallas, TX 75209, USA
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19
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Golomb BA, Han JH, Langsjoen PH, Dinkeloo E, Zemljic-Harpf AE. Statin Use in Relation to COVID-19 and Other Respiratory Infections: Muscle and Other Considerations. J Clin Med 2023; 12:4659. [PMID: 37510774 PMCID: PMC10380486 DOI: 10.3390/jcm12144659] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/04/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Statins have been widely advocated for use in COVID-19 based on large favorable observational associations buttressed by theoretical expected benefits. However, past favorable associations of statins to pre-COVID-19 infection outcomes (also buttressed by theoretical benefits) were unsupported in meta-analysis of RCTs, RR = 1.00. Initial RCTs in COVID-19 appear to follow this trajectory. Healthy-user/tolerator effects and indication bias may explain these disparities. Moreover, cholesterol drops in proportion to infection severity, so less severely affected individuals may be selected for statin use, contributing to apparent favorable statin associations to outcomes. Cholesterol transports fat-soluble antioxidants and immune-protective vitamins. Statins impair mitochondrial function in those most reliant on coenzyme Q10 (a mevalonate pathway product also transported on cholesterol)-i.e., those with existing mitochondrial compromise, whom data suggest bear increased risks from both COVID-19 and from statins. Thus, statin risks of adverse outcomes are amplified in those patients at risk of poor COVID-19 outcomes-i.e., those in whom adjunctive statin therapy may most likely be given. High reported rates of rhabdomyolysis in hospitalized COVID-19 patients underscore the notion that statin-related risks as well as benefits must be considered. Advocacy for statins in COVID-19 should be suspended pending clear evidence of RCT benefits, with careful attention to risk modifiers.
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Affiliation(s)
- Beatrice A. Golomb
- Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA;
| | - Jun Hee Han
- Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA;
| | | | - Eero Dinkeloo
- Navy and Marine Corps Public Health Center, Portsmouth, VA 23704, USA;
| | - Alice E. Zemljic-Harpf
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA 92093, USA
- Veterans Affairs San Diego Healthcare System, San Diego, CA 92093, USA
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20
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Henke K, Odermatt J, Ziaka M, Rudovich N. Subacute Thyroiditis Complicating COVID-19 Infection. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231181560. [PMID: 37351465 PMCID: PMC10280117 DOI: 10.1177/11795476231181560] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/25/2023] [Indexed: 06/24/2023]
Abstract
Subacute thyroiditis (SAT) is a self-limited inflammatory disease and a rare cause of thyrotoxicosis. Although the exact etiology of SAT is not sufficiently understood, it is generally associated to viral infections. Current evidence highlights that SAT may be a potentially uncommon manifestation of ongoing Coronavirus disease 2019 (COVID-19) infection or a post-viral complication of the disease. Despite that SAT is a rare manifestation associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease both in ongoing and resolved COVID-19 infection, the ever-increasing numbers of COVID-19 patients strengthens the possibility that this particular disease entity will be of more immediate concern in the future. The current work aims to summarize the approach of SARS-CoV-2-associated SAT, present its pathophysiology, outline current research evidence found in the literature, and discuss potential differential diagnoses and diagnostic dilemmas through an illustrative case.
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Affiliation(s)
- Katrin Henke
- Department of Medicine, Thun Hospital, Thun, Switzerland
| | - Jonas Odermatt
- Department of Medicine, Thun Hospital, Thun, Switzerland
| | - Mairi Ziaka
- Department of Medicine, Thun Hospital, Thun, Switzerland
| | - Natalia Rudovich
- Department of Medicine, Thun Hospital, Thun, Switzerland
- University of Zurich, Zurich, Switzerland
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21
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Niedzielska J, Chaszczewska-Markowska M, Chojdak-Łukasiewicz J, Berezowski J, Kalra S, Jazwiec P. Case report: Unusual patient with dermatomyositis associated with SARS-CoV-2 infection. Front Neurol 2023; 14:1122475. [PMID: 37273716 PMCID: PMC10236949 DOI: 10.3389/fneur.2023.1122475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/21/2023] [Indexed: 06/06/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak is a major challenge for clinicians. SARS-CoV-2 infection results in coronavirus disease 2019 (COVID-19), and it is best known for its respiratory symptoms. It can also result in several extrapulmonary manifestations such as neurological complications potentially experienced during the course of COVID-19. The association of dermatomyositis (DM) with COVID-19 pathogenesis has not been well-studied. This study aimed to present a previously healthy 37-year-old man, a soldier by profession, with symptoms of DM on the 4th day from the onset of COVID-19. The patient presented DM symptoms with both skin and muscle manifestations. The patient suffered from cough, fever, and fatigue to begin with, and reverse-transcription polymerase chain reaction (RT-PCR) reported positive for SARS-CoV-2 infection. The laboratory findings showed, intra alia, elevated muscle enzymes CK 8253 U/l (N: <145 U/l), a positive test for myositis-specific autoantibodies (anti-Mi-2), electrodiagnostic tests exhibited features of myopathy, with the presence of muscle and skin symptoms. The patient improved with corticosteroids and immunosuppressive agent therapy. In summary, the association between COVID-19 and the development of multi-system autoimmune disorders such as DM remains unclear. Nevertheless, viral infections such as SARS-CoV-2 may likely serve as a trigger.
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Affiliation(s)
- Joanna Niedzielska
- Department of Neurology, Specialist Medical Center in Polanica Zdrój, Polanica-Zdrój, Poland
| | - Monika Chaszczewska-Markowska
- Laboratory of Clinical Immunogenetics and Pharmacogenetics, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | | | - Jakub Berezowski
- Department of Administration, Jan Mikulicz Radecki University Teaching Hospital in Wroclaw, Wroclaw, Poland
| | - Seema Kalra
- Department of Neurology, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Przemysław Jazwiec
- Department of Imaging Diagnostics, Specialist Medical Center in Polanica Zdrój, Polanica-Zdrój, Poland
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22
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Wiersinga WM, Poppe KG, Effraimidis G. Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis. Lancet Diabetes Endocrinol 2023; 11:282-298. [PMID: 36848916 DOI: 10.1016/s2213-8587(23)00005-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 02/26/2023]
Abstract
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.
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Affiliation(s)
- Wilmar M Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Netherlands
| | - Kris G Poppe
- Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Grigoris Effraimidis
- Department of Endocrinology and Metabolic Diseases, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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23
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Chimatapu SN, Ferber CJ, Thambundit A, Okawa ER. Two Cases of Thyroiditis in Adolescents Following COVID-19 Vaccinations. JCEM CASE REPORTS 2023; 1:luad017. [PMID: 37908470 PMCID: PMC10580470 DOI: 10.1210/jcemcr/luad017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Indexed: 11/02/2023]
Abstract
With the onset of the COVID-19 pandemic and the development of widespread vaccination strategies, there have been case reports in the adult literature suggesting an increase in thyroiditis after COVID-19 vaccination. We herein describe 2 children who presented with thyroiditis after COVID-19 vaccination. Two children who received Pfizer-BioNTech COVID-19 messenger RNA vaccines later developed symptoms of thyroid hyperactivity, had positive thyroid-stimulating immunoglobulin (TSI) levels and received treatment directed toward Graves disease. Our case series is the first to demonstrate Graves disease after COVID-19 vaccination in the pediatric population. Given this possibility, it is important for pediatricians to be watchful for symptoms of thyroiditis post vaccination to prevent treatment delays.
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Affiliation(s)
- Sri Nikhita Chimatapu
- Department of Pediatrics, Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Christopher J Ferber
- Department of Pediatrics, Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Apisadaporn Thambundit
- Department of Pediatrics, Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Erin R Okawa
- Department of Pediatrics, Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
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24
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Donner JR, Has P, Topor LS. Increased Incidence and Severity of New Graves Disease Diagnoses in Youth During the COVID-19 Pandemic. Endocr Pract 2023; 29:349-352. [PMID: 36736538 PMCID: PMC9892249 DOI: 10.1016/j.eprac.2023.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/04/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Graves disease (GD), an autoimmune disease of the thyroid, is likely caused by a combination of genetic predisposition and environmental triggers. Recent data suggest that COVID-19 may be associated with the development of autoimmune disease. The aim of this study was to assess the incidence and characteristics of new GD diagnoses in youth prior to and during the COVID-19 pandemic. METHODS We performed a retrospective chart review of all new GD diagnoses in patients aged 0 to 18 years diagnosed at a tertiary care pediatric hospital between January 1, 2018, and December 31, 2021. RESULTS Over a 4-year period, 51 patients had been diagnosed with new-onset GD. We observed an increased incidence in new-onset GD during the pandemic compared with that in the 2 prior years (P = .01). During the pandemic period, heart rates (P = .03) as well as systolic (P = .005) and diastolic (P = .01) blood pressures were higher at initial evaluation, patients more frequently reported palpitations (P = .03) and tremors (P = .04), and an increased proportion of patients required beta-blockade treatment at diagnosis (P = .002). The percentage of patients requiring thionamide treatment and thionamide doses had been similar over time. CONCLUSION We identified an increase in new-onset pediatric GD diagnoses during the COVID-19 pandemic. In addition, youths had increased severity of symptoms and more frequently required beta-blockade treatment at diagnosis. Further study of the relationship between COVID-19 and autoimmune thyroid disease is needed.
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Affiliation(s)
- Julia R Donner
- Department of Pediatrics, Hasbro Children's Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Phinnara Has
- Lifespan Biostatistics, Epidemiology, and Research Design, Brown University, Providence, Rhode Island
| | - Lisa Swartz Topor
- Division of Pediatric Endocrinology, Hasbro Children's Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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25
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Gorini F, Vassalle C. A Literature Review on SARS-CoV-2 and Other Viruses in Thyroid Disorders: Environmental Triggers or No-Guilty Bystanders? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2389. [PMID: 36767756 PMCID: PMC9916247 DOI: 10.3390/ijerph20032389] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 06/18/2023]
Abstract
A growing number of findings indicate a relationship between COVID-19 infection and thyroid dysfunction. This association is also strengthened by knowledge on the potential of viral infections to trigger thyroid disorders, although the exact underlying pathogenetic process remains to be elucidated. This review aimed to describe the available data regarding the possible role of infectious agents, and in particular of SARS-CoV-2, in the development of thyroid disorders, summarizing the proposed mechanisms and levels of evidence (epidemiological, serological or direct presence of the viruses in the thyroid gland) by which the infection could be responsible for thyroid abnormalities/diseases. Novel data on the association and mechanisms involved between SARS-CoV-2 vaccines and thyroid diseases are also discussed. While demonstrating a clear causal link is challenging, numerous clues at molecular and cellular levels and the large amount of epidemiological data suggest the existence of this relationship. Further studies should be taken to further investigate the true nature and strength of this association, to help in planning future preventive and therapeutic strategies for more personal and targeted care with attention to the underlying causes of thyroid dysfunction.
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Affiliation(s)
- Francesca Gorini
- Institute of Clinical Physiology, National Research Council, 56124 Pisa, Italy
| | - Cristina Vassalle
- Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
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26
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Boyle DC, Mullally JA. Thyrotoxicosis after COVID-19 Infection with a Delay in Graves' Disease Antibody Positivity. Case Rep Endocrinol 2023; 2023:8402725. [PMID: 37089262 PMCID: PMC10118873 DOI: 10.1155/2023/8402725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/03/2023] [Accepted: 02/23/2023] [Indexed: 04/25/2023] Open
Abstract
Background and Objective. Mounting evidence implicates COVID-19 as a cause of thyroid dysfunction, including thyrotoxicosis due to both thyroiditis and Graves' disease (GD). In this report, we present a case of thyrotoxicosis following COVID-19 infection that was ultimately found to represent GD with significantly delayed diagnostic serum antibody positivity. Case Report. A 65-year-old woman with a history of uncomplicated COVID-19 infection one month prior, presented to the Emergency Department with exertional dyspnea and palpitations, and was found to be in atrial fibrillation with rapid ventricular response (AF with RVR). Labs showed subclinical hyperthyroidism and the patient was started on a beta-blocker and methimazole. One month later, thyroid-stimulating immunoglobulin (TSI) resulted negative and thyroid function tests had normalized. The clinical picture suggested thyroiditis, and methimazole was stopped. One month later, the patient again presented in AF with RVR, with labs showing overt biochemical thyrotoxicosis. Antibodies were re-tested, and the thyrotropin receptor antibody (TRAb) and TSI resulted positive, confirming GD. Discussion. Most notable in this case is the feature of delayed GD antibody positivity: the diagnostic immunoassay for GD resulted negative one and two months after infection, but was ultimately positive three months after infection. To the authors' knowledge, this represents the longest delayed antibody positivity reported to date, amongst cases of new-onset GD following COVID. Conclusion. The clinical course of GD following COVID-19 infection is highly variable. This case underscores the need for vigilance in monitoring for delayed GD antibody positivity due to the important therapeutic implications of distinguishing thyroiditis from GD.
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Affiliation(s)
- Dennis C. Boyle
- Westchester Medical Center, Department of Medicine, Section of Internal Medicine, Valhalla, USA
| | - Jamie A. Mullally
- Westchester Medical Center, Department of Medicine, Division of Endocrinology and Metabolism, Valhalla, USA
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27
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Nakaizumi N, Fukata S, Hirokawa M, Akamizu T. Painless thyroiditis incidentally diagnosed following SARS-CoV-2 infection. BMJ Case Rep 2022; 15:e252837. [PMID: 36455982 PMCID: PMC9716833 DOI: 10.1136/bcr-2022-252837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/05/2022] Open
Abstract
A euthyroid woman in her 50s with papillary thyroid cancer and primary hyperparathyroidism was referred to our hospital for surgery. Her surgery was scheduled for 4 months later but was postponed because she was diagnosed with COVID-19. Five months after the first visit, she was admitted to our hospital to undergo the planned thyroid lobectomy and parathyroidectomy. Her blood tests on admission showed thyrotoxicosis, with negative thyroid-stimulating hormone receptor and thyroid-stimulating antibody. Notably, her anti-thyroglobulin antibody and anti-thyroid peroxidase antibody, which were originally negative, became positive after SARS-CoV-2 infection. She was diagnosed with painless thyroiditis. Her general condition and vital signs were stable, and the surgery was cautiously performed. Histopathological examination of the resected thyroid revealed papillary thyroid carcinoma, and the findings were consistent with painless thyroiditis. Her postoperative course was uneventful, and her thyroid function improved 2 weeks after the operation.
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Affiliation(s)
| | - Shuji Fukata
- Internal Medicine, Kuma Hospital, Kobe, Hyogo-ken, Japan
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28
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Lioulios G, Tsouchnikas I, Dimitriadis C, Giamalis P, Pella E, Christodoulou M, Stangou M, Papagianni A. Two Cases of Autoimmune Thyroid Disorders after COVID Vaccination in Dialysis Patients. Int J Mol Sci 2022; 23:ijms231911492. [PMID: 36232790 PMCID: PMC9570111 DOI: 10.3390/ijms231911492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/18/2022] Open
Abstract
SARS-CoV-2 infection and vaccination have been associated with autoimmune thyroid dysfunctions. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) and molecular mimicry have been referred to as potential causes. Such a case has not been reported in immunocompromised end-stage renal disease (ESRD) patients. Herein we present two dialysis patients with no previous history of thyroid disease who developed immune mediated thyroid disorders after BNT162b mRNA vaccine against SARS-CoV-2. The first patient is a 29-year-old man on hemodialysis diagnosed with Grave’s disease four months post-vaccination and the second one is a 67-year-old female on peritoneal dialysis who developed Hashimoto’s thyroiditis two months post-vaccination. Grave’s disease is uncommon in dialysis patients, whereas Hashimoto’s thyroiditis has a higher incidence in this population. Time proximity in both cases suggests potential causality. To our knowledge, this is the first report of de novo immune-mediated thyroid disorders in dialysis patients following vaccination against SARS-CoV-2.
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29
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Churilov LP, Normatov MG, Utekhin VJ. Molecular Mimicry between SARS-CoV-2 and Human Endocrinocytes: A Prerequisite of Post-COVID-19 Endocrine Autoimmunity? PATHOPHYSIOLOGY 2022; 29:486-494. [PMID: 36136066 PMCID: PMC9504401 DOI: 10.3390/pathophysiology29030039] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 12/28/2022] Open
Abstract
Molecular mimicry between human and microbial/viral/parasite peptides is common and has long been associated with the etiology of autoimmune disorders provoked by exogenous pathogens. A growing body of evidence accumulated in recent years suggests a strong correlation between SARS-CoV-2 infection and autoimmunity. The article analyzes the immunogenic potential of the peptides shared between the SARS-CoV-2 spike glycoprotein (S-protein) and antigens of human endocrinocytes involved in most common autoimmune endocrinopathies. A total of 14 pentapeptides shared by the SARS-CoV-2 S-protein, thyroid, pituitary, adrenal cortex autoantigens and beta-cells of the islets of Langerhans were identified, all of them belong to the immunoreactive epitopes of SARS-CoV-2. The discussion of the findings relates the results to the clinical correlates of COVID-19-associated autoimmune endocrinopathies. The most common of these illnesses is an autoimmune thyroid disease, so the majority of shared pentapeptides belong to the marker autoantigens of this disease. The most important in pathogenesis of severe COVID-19, according to the authors, may be autoimmunity against adrenals because their adequate response prevents excessive systemic action of the inflammatory mediators causing cytokine storm and hemodynamic shock. A critique of the antigenic mimicry concept is given with an assertion that peptide sharing is not a guarantee but only a prerequisite for provoking autoimmunity based on the molecular mimicry. The latter event occurs in carriers of certain HLA haplotypes and when a shared peptide is only used in antigen processing
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Affiliation(s)
- Leonid P. Churilov
- The Laboratory of the Mosaic of Autoimmunity, Department of Pathology, Saint Petersburg State University, 199034 Saint Petersburg, Russia
- The St. Petersburg Research Institute of Phthisiopulmonology, 194064 Saint Petersburg, Russia
- Correspondence: (L.P.C.); (M.G.N.); (V.J.U.)
| | - Muslimbek G. Normatov
- The Laboratory of the Mosaic of Autoimmunity, Department of Pathology, Saint Petersburg State University, 199034 Saint Petersburg, Russia
- Correspondence: (L.P.C.); (M.G.N.); (V.J.U.)
| | - Vladimir J. Utekhin
- The Laboratory of the Mosaic of Autoimmunity, Department of Pathology, Saint Petersburg State University, 199034 Saint Petersburg, Russia
- The Department of Pathophysiology, Saint Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
- Correspondence: (L.P.C.); (M.G.N.); (V.J.U.)
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30
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Mehta S, Gill N. Retinal Vasculitis in a Patient With Mixed Connective Tissue Disease Following COVID-19 Infection: Correlation or Coincidence? Cureus 2022; 14:e26365. [PMID: 35911323 PMCID: PMC9328413 DOI: 10.7759/cureus.26365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/05/2022] Open
Abstract
We report the systemic and ophthalmic findings in a female patient with mixed connective tissue disease (MCTD) who subsequently developed retinal vasculitis following coronavirus disease 2019 (COVID-19) reinfection. The patient was a known case of MCTD maintained in remission on immunosuppressive treatment. She subsequently developed retinal vasculitis with areas of capillary non-perfusion in the right eye. This was a finding not seen previously. She was started on an enhanced immunosuppressive regimen along with scatter laser photocoagulation. COVID-19 has been reported to lead to the development of autoimmune disease, both de novo as well as the worsening of pre-existing disease. The onset of retinal vasculitis may potentially be due to a post-COVID-19 exacerbation of her pre-existing MCTD. Physicians should be aware of this possibility and screen for the same.
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31
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Boaventura P, Macedo S, Ribeiro F, Jaconiano S, Soares P. Post-COVID-19 Condition: Where Are We Now? Life (Basel) 2022; 12:life12040517. [PMID: 35455008 PMCID: PMC9029703 DOI: 10.3390/life12040517] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 02/06/2023] Open
Abstract
COVID-19 is currently considered a systemic infection involving multiple systems and causing chronic complications. Compared to other post-viral fatigue syndromes, these complications are wider and more intense. The most frequent symptoms are profound fatigue, dyspnea, sleep difficulties, anxiety or depression, reduced lung capacity, memory/cognitive impairment, and hyposmia/anosmia. Risk factors for this condition are severity of illness, more than five symptoms in the first week of the disease, female sex, older age, the presence of comorbidities, and a weak anti-SARS-CoV-2 antibody response. Different lines of research have attempted to explain these protracted symptoms; chronic persistent inflammation, autonomic nervous system disruption, hypometabolism, and autoimmunity may play a role. Due to thyroid high ACE expression, the key molecular complex SARS-CoV-2 uses to infect the host cells, thyroid may be a target for the coronavirus infection. Thyroid dysfunction after SARS-CoV-2 infection may be a combination of numerous mechanisms, and its role in long-COVID manifestations is not yet established. The proposed mechanisms are a direct effect of SARS-CoV-2 on target cells, an indirect effect of systemic inflammatory immune response, and a dysfunction of the hypothalamic-pituitary-thyroid (HPT) axis leading to decreased serum TSH. Only a few studies have reported the thyroid gland status in the post-COVID-19 condition. The presence of post-COVID symptoms deserves recognition of COVID-19 as a cause of post-viral fatigue syndrome. It is important to recognize the affected individuals at an early stage so we can offer them the most adequate treatments, helping them thrive through the uncertainty of their condition.
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Affiliation(s)
- Paula Boaventura
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Rua Júlio Amaral de Carvalho 45, 4200-135 Porto, Portugal; (S.M.); (F.R.); (P.S.)
- Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal
- Faculty of Medicine of the University of Porto (FMUP), 4200-319 Porto, Portugal
- Correspondence:
| | - Sofia Macedo
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Rua Júlio Amaral de Carvalho 45, 4200-135 Porto, Portugal; (S.M.); (F.R.); (P.S.)
- Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal
| | - Filipa Ribeiro
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Rua Júlio Amaral de Carvalho 45, 4200-135 Porto, Portugal; (S.M.); (F.R.); (P.S.)
- Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal
| | - Sónia Jaconiano
- School of Architecture, Art and Design (EAAD), University of Minho, 4800-058 Guimarães, Portugal;
| | - Paula Soares
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Rua Júlio Amaral de Carvalho 45, 4200-135 Porto, Portugal; (S.M.); (F.R.); (P.S.)
- Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Rua Alfredo Allen 208, 4200-135 Porto, Portugal
- Faculty of Medicine of the University of Porto (FMUP), 4200-319 Porto, Portugal
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32
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Zhang Z, Fang T, Lv Y. Causal associations between thyroid dysfunction and COVID-19 susceptibility and severity: A bidirectional Mendelian randomization study. Front Endocrinol (Lausanne) 2022; 13:961717. [PMID: 36147565 PMCID: PMC9485491 DOI: 10.3389/fendo.2022.961717] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/15/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Observational studies have reported an association between coronavirus disease 2019 (COVID-19) risk and thyroid dysfunction, but without a clear causal relationship. We attempted to evaluate the association between thyroid function and COVID-19 risk using a bidirectional two-sample Mendelian randomization (MR) analysis. METHODS Summary statistics on the characteristics of thyroid dysfunction (hypothyroidism and hyperthyroidism) were obtained from the ThyroidOmics Consortium. Genome-wide association study statistics for COVID-19 susceptibility and its severity were obtained from the COVID-19 Host Genetics Initiative, and severity phenotypes included hospitalization and very severe disease in COVID-19 participants. The inverse variance-weighted (IVW) method was used as the primary analysis method, supplemented by the weighted-median (WM), MR-Egger, and MR-PRESSO methods. Results were adjusted for Bonferroni correction thresholds. RESULTS The forward MR estimates show no effect of thyroid dysfunction on COVID-19 susceptibility and severity. The reverse MR found that COVID-19 susceptibility was the suggestive risk factor for hypothyroidism (IVW: OR = 1.577, 95% CI = 1.065-2.333, P = 0.022; WM: OR = 1.527, 95% CI = 1.042-2.240, P = 0.029), and there was lightly association between COVID-19 hospitalized and hypothyroidism (IVW: OR = 1.151, 95% CI = 1.004-1.319, P = 0.042; WM: OR = 1.197, 95% CI = 1.023-1.401, P = 0.023). There was no evidence supporting the association between any phenotype of COVID-19 and hyperthyroidism. CONCLUSION Our results identified that COVID-19 might be the potential risk factor for hypothyroidism. Therefore, patients infected with SARS-CoV-2 should strengthen the monitoring of thyroid function.
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Affiliation(s)
- Zhihao Zhang
- Department of Thyroid Breast Surgery, Xi’an NO.3 Hospital, the Affiliated Hospital of Northwest University, Xi'an, China
| | - Tian Fang
- Department of Medical Oncology, Cancer Center, West China Hospital of Sichuan University, Chengdu, China
| | - Yonggang Lv
- Department of Thyroid Breast Surgery, Xi’an NO.3 Hospital, the Affiliated Hospital of Northwest University, Xi'an, China
- *Correspondence: Yonggang Lv,
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33
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Triantafyllidis KK, Giannos P, Stathi D, Kechagias KS. Graves' disease following vaccination against SARS-CoV-2: A systematic review of the reported cases. Front Endocrinol (Lausanne) 2022; 13:938001. [PMID: 36237182 PMCID: PMC9552880 DOI: 10.3389/fendo.2022.938001] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/23/2022] [Indexed: 01/08/2023] Open
Abstract
The newly developed COVID-19 vaccines have established a safe profile, yet some individuals experience a wide range of adverse events. Recently, thyroid dysfunction, including Graves' disease, has been observed after administration of different COVID-19 vaccines, although causality remains a matter of debate. The aim of this systematic review was to examine the available literature and provide an overview of reported cases of Graves' disease following COVID-19 vaccination. We identified 21 eligible articles which included 57 patients with Graves' disease following COVID-19 vaccination. Fourteen participants were males (25%, 14/57) and 43 (75%, 44/57) were females with a mean age of 44.3 years. The most common presenting symptom was palpitations (63%, 27/43) followed by weight loss (35%, 15/43). The majority of patients received thionamides (47%, 25/53). The clinical status after treatment was provided for 37 patients and it was improved in the majority of them (84%, 31/37). Graves' disease is possibly a condition clinicians may expect to encounter in patients receiving COVID-19 vaccines. While the above adverse event is rare, considering the scarcity of available data in scientific literature, and causality is not yet confirmed, the increased awareness of clinicians and the early recognition of the disorder are important for the optimal management of these patients.
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Affiliation(s)
- Konstantinos Katsikas Triantafyllidis
- Society of Meta-research and Biomedical Innovation, London, United Kingdom
- Department of Nutrition and Dietetics, Homerton University Hospital Foundation Trust, London, United Kingdom
| | - Panagiotis Giannos
- Society of Meta-research and Biomedical Innovation, London, United Kingdom
- Department of Life Sciences, Faculty of Natural Sciences, Imperial College London, London, United Kingdom
| | - Dimitra Stathi
- Society of Meta-research and Biomedical Innovation, London, United Kingdom
- Department of Endocrinology and Diabetes, Guy’s and St Thomas’ National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Konstantinos S. Kechagias
- Society of Meta-research and Biomedical Innovation, London, United Kingdom
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, United Kingdom
- *Correspondence: Konstantinos S. Kechagias,
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McCowan R, Wild E, Lucas-Herald A, McNeilly J, Mason A, Wong S, Ahmed SF, Shaikh MG. The effect of COVID-19 on the presentation of thyroid disease in children. Front Endocrinol (Lausanne) 2022; 13:1014533. [PMID: 36325445 PMCID: PMC9618596 DOI: 10.3389/fendo.2022.1014533] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/27/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Although studies suggest a potential link between COVID-19 and thyroid dysfunction in adults, there are insufficient data to confirm that association in children, and whether there is any effect on presentation to healthcare services. AIMS To identify whether presentations of thyroid dysfunction in children to a tertiary paediatric hospital changed as a result of the COVID-19 pandemic. METHODS A retrospective case note review was conducted of all children with abnormal thyroid function tests between 1st January 2016 and 31st December 2021 at a tertiary paediatric endocrine centre in the United Kingdom. RESULTS Overall, 244 children whose first presentation was within the timeframe of interest were included in this study, with a median age (range) of 11.5 (6.1, 16.8) years. Of these, 43 (18%) were hyperthyroid and 201 (82%) were hypothyroid. The greatest number of thyroid presentations occurred in 2021 (n=60, 25% of total over time period) and the fewest in 2020 (n=10, 4% of total over time period). Prior to this, the median (range) number of presentations per year was 34 (28, 39). There were no statistically significant differences in biochemistry, antibody status or other clinical characteristics between those who presented with hyperthyroidism prior to the pandemic or after. In those with hypothyroidism, baseline biochemistry was similar between the 2 groups, but the presence of other autoimmune conditions was greater pre-pandemic (17.2% vs 15.0%, p=0.03). In addition, patients were more likely to have transient thyroid dysfunction, which did not require treatment post-pandemic (70.0% vs 49.6%, p=0.0086). CONCLUSIONS Although overall rates of presentation with thyroid dysfunction have not altered since the first wave of the COVID-19 pandemic, presentations with transient thyroid dysfunction, not requiring ongoing treatment have increased. Further research regarding the relationship between COVID-19 and thyroid function in children and young people, is needed.
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Affiliation(s)
- Rebecca McCowan
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Glasgow, United Kingdom
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Edith Wild
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Glasgow, United Kingdom
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Angela K. Lucas-Herald
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Glasgow, United Kingdom
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Jane McNeilly
- Department of Clinical Biochemistry, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Avril Mason
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Glasgow, United Kingdom
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Sze Choong Wong
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Glasgow, United Kingdom
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - S. Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Glasgow, United Kingdom
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - M. Guftar Shaikh
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Glasgow, United Kingdom
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
- *Correspondence: M. Guftar Shaikh,
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