Thyroid Eye Disease Following COVID-19 Vaccine in a Patient With a History Graves' Disease: A Case Report

Risk of abducens nerve palsy following COVID-19 vaccination

PURPOSE

To investigate the prevalence and risk of new-onset abducens nerve palsy and acute-onset diplopia following mRNA COVID-19 vaccination.

METHODS

In this retrospective, population-based study, patient data from the COVID-19 Research Network of TriNetX was searched via the TriNetX Analytics platform for patients who received specific vaccinations based on Common Procedural Technology codes. We recorded instances of newly diagnosed abducens nerve palsy and diplopia within 21 days following each vaccination event.

RESULTS

Of the 3,545,224 patients (mean age at vaccination, 46.2 ± 21.3 years) who received the mRNA COVID-19 vaccine, 12 (<0.0001%) patients had a new diagnosis of abducens nerve palsy and 453 (0.013%) had acute-onset diplopia within 21 days of first dose of COVID-19 vaccination. After propensity score matching, the relative risk for new abducens nerve palsy diagnosis after the first dose of COVID-19 vaccination was not significantly different from that after influenza (RR, 0.77), Tdap (RR, 1.0), or the second dose of the COVID-19 vaccinations (RR, 1.00). Furthermore, there was a lower risk of abducens nerve palsy diagnosis after the first dose of the COVID-19 vaccination compared with the risk after COVID-19 infection (RR, 0.15).

CONCLUSIONS

The risk of a new abducens nerve palsy diagnosis following the first dose of the COVID-19 vaccine is lower than the risk associated with COVID-19 infection itself. There is no evidence to suggest a causal relationship between COVID-19 vaccination and the development of abducens nerve palsy.

Acute onset ocular myasthenia gravis after vaccination with the Oxford-AstraZeneca COVID-19 vaccine

Myasthenia gravis (MG) is an autoimmune disease that results in muscle weakness and fatigability. Extraocular involvement may be the first sign of disease. It may be triggered by infections, stress, or medications. We describe a first reported case of ocular MG induced by the viral vector Oxford-AstraZeneca coronavirus disease (COVID-19) vaccine, detail the pathophysiology of vaccine-induced MG, and explore the impact of COVID-19 on MG patients.

Thyroid Eye Disease as Initial Manifestation of Graves' Disease Following Viral Vector SARS-CoV-2 Vaccine: Report of a Case and Review of the Literature

COVID-19, a contagious disease caused by the novel coronavirus SARS-CoV-2, emerged in 2019 and quickly became a pandemic, infecting more than 700 million people worldwide. The disease incidence, morbidity and mortality rates have started to decline since the development of effective vaccines against the virus and the widespread immunization of the population. SARS-CoV-2 vaccines are associated with minor local or systemic adverse reactions, while serious adverse effects are rare. Thyroid-related disorders have been reported after vaccination for COVID-19, and Graves' disease (GD) is the second most common amongst them. Thyroid eye disease (TED), an extrathyroidal manifestation of GD, is rarely observed post-COVID-19 vaccination. All TED cases followed mRNA-based vaccinations, but two new onset mild TED cases post-viral vector vaccine (ChAdox1nCoV-19) have also been reported. We report the case of a 63-year-old woman who presented with new onset hyperthyroidism and moderate-to-severe and active TED 10 days after she received the first dose of a viral vector vaccine against SARS-CoV-2. This is the first case of moderate-to-severe TED after such a vaccine. Our patient was initially treated with intravenous glucocorticoids, and subsequently with intravenous rituximab, due to no response. The disease was rendered inactive after rituximab, but constant diplopia persisted, and the patient was referred for rehabilitative surgery.

Orbital Inflammatory Pseudotumor following mRNA COVID-19 Vaccination

The authors present a case of orbital pseudotumor after mRNA COVID-19 vaccination. A 40-year-old otherwise healthy woman was referred to our oculoplastics unit because of left blepharoptosis of 2 months duration starting 1 week after she received her first Pfizer-BioNTech mRNA vaccination. On presentation, her best-corrected visual acuity was 20/20 in each eye. The external examination revealed left blepharoptosis and mild upper eyelid swelling. Orbital magnetic resonance imaging revealed left lacrimal gland enlargement with homogeneous contrast enhancement and diffuse mild enlargement of the left lateral and superior rectus muscles. The results of the extended workup for autoimmune and infectious etiologies and the systemic examination findings were normal. Systemic corticosteroids were started for the orbital pseudotumor. The presented case of orbital pseudotumor development after the mRNA vaccine may be considered to be an immunological process targeting the orbital tissue following immunization, although the cause-effect relationship remains uncertain.

Unilateral proptosis in a patient with thyroid eye disease: A case report

Unilateral proptosis is an abnormality in which one eye sticks out forward more than the other. Bulging of the eye is commonly seen in Graves' ophthalmopathy, but it's mostly bilateral. Thyroid eye disease presents as the most common extrathyroidal manifestation of Graves' disease, and rarely leads to unilateral proptosis. A 25-year-old female with a history of weight loss, menstrual irregularities, and palpitations presented with progressive right eye bulging, which was further confirmed by magnetic resonance imaging and biochemical investigations. Magnetic resonance imaging of the orbit revealed unilateral extraocular muscle enlargement and enhancement with sparing of the tendons. Timely therapy is crucial for reversing the ocular manifestations of thyroid eye disease.

COVID-19 vaccination and thyroiditis

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

Ocular motility disorders following coronavirus disease-19 vaccination

PURPOSE

To describe clinical manifestations and short-term prognosis of ocular motility disorders following coronavirus disease-2019 (COVID-19) vaccination.

METHODS

Ocular motility disorders were diagnosed by clinical assessment, high-resolution magnetic resonance imaging, and laboratory testing. Clinical manifestations, short-term prognosis, and rate of complete recovery were analyzed.

RESULTS

Sixty-three patients (37 males, 26 females) with a mean age of 61.6 ± 13.3 years (range, 22-81 years) were included in this study. Among 61 applicable patients with sufficient information regarding medical histories, 38 (62.3%) had one or more significant underlying past medical histories including vasculopathic risk factors. The interval between initial symptoms and vaccination was 8.6 ± 8.2 (range, 0-28) days. Forty-two (66.7%), 14 (22.2%), and 7 (11.1%) patients developed symptoms after the first, second, and third vaccinations, respectively. One case of internuclear ophthalmoplegia, 52 cases of cranial nerve palsy, two cases of myasthenia gravis, six cases of orbital diseases (such as myositis, thyroid eye disease, and IgG-related orbital myopathy), and two cases of comitant vertical strabismus with acute onset diplopia were found. Among 42 patients with follow-up data (duration: 62.1 ± 40.3 days), complete improvement, partial improvement, no improvement, and exacerbation were shown in 20, 15, 3, and 4 patients, respectively.

CONCLUSION

This study provided various clinical features of ocular motility disorders following COVID-19 vaccination. The majority of cases had a mild clinical course while some cases showed a progressive nature. Close follow-up and further studies are needed to elucidate the underlying mechanisms and long-term prognosis.

New Onset or Deterioration of Thyroid Eye Disease After mRNA SARS-CoV-2 Vaccines: Report of 2 Cases and Literature Review

CONTEXT

Occurrence of Graves' disease (GD) has been reported following SARS-CoV-2 vaccine administration, but little is known about thyroid eye disease (TED) after SARS-CoV-2 vaccination.

OBJECTIVE

We describe 2 cases of TED activation following mRNA SARS-CoV-2 vaccination and review additional cases reported in the literature.

METHODS

We report 2 cases of TED activation following SARS-CoV-2 vaccination: 1 case of TED worsening in a patient with GD, and 1 of de novo active TED progressing to dysthyroid optic neuropathy in a patient with a history of Hashimoto hypothyroidism. Our literature search revealed 8 additional reported TED cases associated with SARS-CoV-2 vaccination until June 2022. We review the characteristics, duration, and management of TED following SARS-CoV-2 vaccination in these cases.

RESULTS

Of all 10 reported TED cases following SARS-CoV-2 vaccination, 4 developed new-onset TED and 6 previously stable TED cases experienced significant deterioration. Six patients had known GD and 2 patients had Hashimoto thyroiditis. Two cases progressed to dysthyroid optic neuropathy, 6 had moderate/severe active disease, and 2 had mild disease that did not require treatment. Seven TED cases received teprotumumab and had a favorable response, 2 of whom had prior limited response to initial prednisone or methylprednisolone and tocilizumab therapy.

CONCLUSION

New diagnosis or deterioration of TED after mRNA SARS-CoV-2 vaccination can occur, with most cases described in patients with underlying autoimmune thyroid disease. Our report raises awareness to this potential complication to promote early recognition and prompt management of TED associated with mRNA SARS-CoV-2 vaccines. Further studies are needed to explore the mechanism, risk factors, prevention, and treatment of TED following mRNA SARS-CoV-2 vaccination.

Graves' orbitopathy post-SARS-CoV-2 vaccines: report on six patients

CONTEXT

Autoimmune and inflammatory thyroid diseases (Graves' disease, subacute thyroiditis, chronic autoimmune thyroiditis) have been reported following SARS-CoV-2 vaccines but Graves' orbitopathy (GO) post-COVID-19 vaccination is uncommon.

METHODS

We describe six new patients seen in Endocrinology Departments with Outpatient Clinics for GO following SARS-CoV-2 vaccines in France.

RESULTS

After COVID-19 vaccination, GO was observed in six patients (three men, three women, mean age 53 ± 6 years) with a personal past history of Graves' disease (5/6) or orbitopathy (4/6). New-onset (n = 2) or recurrence (n = 4) of GO was observed following mRNA vaccines after the first (3/6) or second (3/6) dose, with the mean time from vaccination to GO at 23.8 ± 10.4 days. In one patient, thyrotoxicosis was confirmed by increased free T4 and low TSH concentrations while others had normal TSH levels, during chronic levothyroxine treatment in three patients. Four patients had significant anti-TSH receptor antibodies levels. According to the severity and activity of GO, the patients were treated using selenium (n = 2), intravenous glucocorticoids (n = 2), teprotumumab (n = 1), tocilizumab (n = 2) and orbital decompression (n = 1) with a significant improvement in GO signs and symptoms observed by most patients.

CONCLUSION

In this study, we report the main data from six new patients with GO following SARS-CoV-2 vaccines. Clinicians need to be aware of the risk of new-onset or recurrent GO in predisposed patients with autoimmune thyroid diseases after COVID-19 vaccination. This study should not raise any concerns regarding SARS-CoV-2 vaccination since the risk of COVID-19 undoubtedly outweighs the incidence of uncommon GO after SARS-CoV-2 vaccination.

Reactivation of Graves' Disease and Thyroid Eye Disease following COVID-19 Vaccination - A Case Report

A 51-year-old male had a history of well-controlled Graves' disease (GD) under regular follow-up, and thyroid eye disease (TED) with post bilateral orbital decompression. However, after COVID-19 vaccination, recrudescence of GD and moderate-to-severe TED were diagnosed by increased thyroxine levels and decreased thyrotropin levels in serum, and positive results of thyrotropin receptor antibody and thyroid peroxidase antibody. Weekly intravenous methylprednisolone was prescribed. Symptoms gradually improved accompanied with reduction in proptosis: 1.5 mm of the OD and 2.5 mm of the OS. Possible pathophysiological mechanisms discussed included molecular mimicry theory, autoimmune/inflammatory syndrome induced by adjuvants, and certain genetic predisposition of human leukocyte antigen. Physicians should remind patients to seek treatment if the symptoms and signs of TED recur following COVID-19 vaccination.

Four cases of Graves' disease following viral vector severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) vaccine

Mass immunization has led to a decrease in the transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) worldwide. At the same time, awareness regarding possible adverse effects of newly developed vaccines is critical. The present study was undertaken to report the cases of Graves' disease occurring after administration of viral vector vaccine (ChAdox1nCoV-19) and describe the clinical profile, response to treatment, and effect of administration of a second dose in patients developing Graves' disease. Four cases of Graves' disease after administration of the vaccine were noted. Two of these had a mild thyroid eye disease. Three cases were female and had a family/self-history of autoimmune disease. All cases responded well to treatment and became euthyroid within two to four months. Two patients exhibited worsening thyrotoxicosis after receiving a second dose of the vaccine. We propose that the temporal relationship between administration of the vaccine and the onset of symptoms establishes Graves' disease as an adverse event after the SARS-CoV-2 viral vector vaccine. Close follow-up is advisable in individuals developing Graves' disease after SARS-CoV-2 vaccination.

Autoimmune and inflammatory thyroid diseases following vaccination with SARS-CoV-2 vaccines: from etiopathogenesis to clinical management

Since the Covid-19 pandemic emerged in 2019, several adenoviral-vectored, mRNA-based and inactivated whole-virus vaccines have been developed. A massive vaccination campaign has been undertaken around the world, and an increasing number of SARS-CoV-2 vaccine-induced thyroid diseases have been described in the literature. Subacute thyroiditis has been reported in 52 patients, mean age 45.5 ± 1.8 years, mainly in women (n = 39). Graves' disease is more frequent in women (n = 22) than in men (n = 10), mean age 46.2 ± 2.6 years, reported as new onset, recurrent or exacerbation of well-controlled hyperthyroidism. The mean time to symptoms onset is 9.0 ± 0.8 days in subacute thyroiditis, and 15.1 ± 2.6 days in Graves' patients. Rare patients (n = 6) present silent or painless autoimmune thyroiditis. Thyroid function and autoimmune tests, inflammatory markers, thyroid echography with colour flow Doppler, radio-activity uptake on thyroid scan, medical treatment and follow-up are described and compared in patients with SARS-CoV-2 vaccine-induced thyroid diseases. The underlying pathogenic mechanisms of vaccine-induced thyroid diseases, molecular mimicry (various SARS-CoV-2 proteins sharing a genetic homology with a large heptapeptide human protein) or autoimmune/inflammatory syndrome induced by adjuvants (ASIA) are discussed in the context of predisposition or genetic susceptibility. The benefits of SARS-CoV-2 vaccination far outweigh the potential vaccine-induced adverse effects, but clinicians should be aware of possible autoimmune and inflammatory thyroid diseases, and can advise patients to seek medical assistance when experiencing anterior neck pain, fever or palpitations following SARS-CoV-2 vaccines. Further studies are warranted to investigate the etiopathogenesis and to clarify the factors which predispose patients to SARS-CoV-2 vaccine-induced thyroid diseases.

SARS-CoV-2 vaccine may trigger thyroid autoimmunity: real-life experience and review of the literature

PURPOSE

SARS-CoV-2 infection can be associated with destructive thyroiditis and triggers thyroid autoimmunity. More recent evidence suggests that SARS-CoV-2 vaccines may also be associated with permanent or transient thyroid dysfunction in susceptible individuals.

METHODS

We observed three patients who developed/exacerbated autoimmune thyroid diseases (AITDs) shortly after receiving mRNA-based vaccines against SARS-CoV2. Clinical histories are reported, and relevant literature in the field is summarized.

RESULTS

Our case series gives a description of the full spectrum of autoimmune disorders that may occur after SARS-CoV-2 vaccines administration, ranging from a case of new-onset Graves' disease to autoimmune hypothyroidism in two patients with pre-existing AITDs. Our three patients had a personal and/or family history of autoimmune disorders, suggesting that genetic predisposition is an important risk factor for the development of AITDs following vaccination. Moreover, our real-life experience demonstrates that persistent hypothyroidism may occur in the long run and should be overlooked; subjects with a previous AITDs are at risk of developing it. Reviewing the pertinent literature up to date Graves' disease is the most common vaccine-related AITDs with up to 51 cases reported in the literature, occurring mainly in female patients with no personal history of AIDTs, while only a case of autoimmune hypothyroidism has been reported so far.

CONCLUSIONS

SARS-CoV-2 vaccines can trigger autoimmune reactions and the present case series contributes to make clinicians aware of full spectrum of AITDs that may occur following vaccination. Thyroid function monitoring is recommended, mainly in subjects with a personal/family history of AITDs.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Schilddrüse und SARS-CoV-2

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

Ocular adverse effects of COVID-19 vaccines: A systematic review

The COVID-19 pandemic has led to the development and rollout of several vaccines worldwide at unprecedented pace. This systematic review of published literature has been undertaken to spread awareness among general physicians and ophthalmologists about the various reported adverse effects in the eye following COVID-19 vaccination. A systematic search was performed on 25 January 2022 through PuBMed, Medline and Google scholar for publications on ocular adverse effects after COVID-19 vaccination. One brief communication, four retrospective case series, sixteen case reports, and five letters to editors were included. Ocular manifestations most commonly appear in the uvea and retina. Other manifestations are seen on the eyelid, cornea and ocular surface, and in cranial nerves innervating the eye. The incidence rate of these manifestations is quite low after COVID-19 vaccinations. Our systematic review meticulously enumerates various adverse effects of COVID -19 vaccine on the eye. Most of these adverse effects are transient and observed to resolve without any sequelae except for cases of retinal and ophthalmic vascular occlusions and corneal graft rejections. An emphasis on close follow-up and a need to delay vaccination and modified therapy to control flare up of signs and symptoms in certain sub-populations, Graves' disease (autoimmune etiology), pre-existing uveal inflammation and corneal graft cases are warranted. We need long-term, larger, multicentric studies to substantiate our findings and establish the causal relationship with certainty. Mass vaccinations to curb this pandemic after outweighing the ocular risks associated with it is warranted.

Teprotumumab in advanced reactivated thyroid eye disease

Purpose

To report the case of a patient with reactivated, refractory thyroid eye disease (TED) treated with teprotumumab.

Observations

A 51-year-old female with a 16-year history of thyroid eye disease previously treated with orbital decompression and multiple eyelid surgeries presented in a recurrent flare of the disease. The disease recurrence was refractory to intravenous steroid therapy and only partially responsive to oral steroid therapy, and the patient developed dysthyroid optic neuropathy in the right eye with decreased visual acuity and color vision. Clinical activity score was 8/10 and proptosis measurements were 27 mm OD and 26 mm OS. The patient underwent treatment with eight infusions of teprotumumab coinciding with a low taper of oral prednisone and experienced resolution of dysthyroid optic neuropathy, decrease of clinical activity score to 1, and dramatic improvement in proptosis (17 mm OD, 17 mm OS) and extraocular muscle size on imaging. Thirty weeks after completion of teprotumumab and 2 weeks after the second dose of the COVID vaccine, she experienced another flare and subsequently underwent bilateral orbital decompressions.

Conclusion

This case report suggests teprotumumab may be used in patients with reactivation of longstanding thyroid eye disease. Reduction of extraocular muscle size and improvement in proptosis suggest teprotumumab may be disease-modifying even in advanced cases.

COVID-19 and the eye: alternative facts The 2022 Bowman Club, David L. Easty lecture

In addition to catastrophic loss of life, and dramatic and unwanted alterations to the daily lives of those left behind, the COVID-19 pandemic has fostered the publication and dissemination of an unprecedented quantity of peer-reviewed medical and scientific publications on a single subject. In particular, the ophthalmic literature is now replete with clinical and laboratory studies on putative eye involvement by SARS-CoV-2, the aetiologic agent of COVID-19. In this review, we critically appraise the published literature on COVID-19, and suggest that the quality of scientific peer review and editorial decision-making also suffered during the COVID-19 pandemic.

SARS-CoV-2 Vaccine-induced Thyroiditis: Safety of Revaccinations and Clinical Follow-up

CONTEXT

The number of reported cases with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccine-induced subacute thyroiditis (SAT) and Graves' disease (GD) is growing. However, active debate continues about managing such side effects and the safety of repeat or booster doses of the vaccines in such cases.

OBJECTIVES

This study aims to present long-term clinical follow-up of SARS-CoV-2 vaccine-induced SAT or GD cases and provide data regarding the safety of revaccinations.

METHODS

Patients diagnosed with SARS-CoV-2 vaccine-induced SAT or GD were included. Data regarding the long-term clinical follow-up of SARS-CoV-2 vaccine-induced SAT and GD cases and outcomes of repeat or booster SARS-CoV-2 vaccinations were documented. The literature, including cases of SARS-CoV-2 vaccine-induced SAT or GD, was reviewed.

RESULTS

Fifteen patients with SARS-CoV-2 vaccine-induced SAT and 4 with GD were included. Pfizer/BioNTech COVID-19 vaccine (BNT162b2) was associated with symptoms in a majority of cases with SAT and all with GD. Median time from vaccination to symptom onset was 7 and 11.5 days, respectively, while 7 and 2 patients required medical treatment in SAT and GD groups, respectively. Remission was documented in 10 SAT patients, with a median time to remission of 11.5 weeks. No exacerbation/recurrence of SAT occurred in 7 of 9 patients who received a repeat vaccination dose, while symptoms of SAT worsened following the second vaccination in 2 cases. None of the patients experienced severe side effects that could be associated with revaccinations.

CONCLUSIONS

Revaccinations appear to be safe in patients with SARS-CoV-2 vaccine-induced SAT cases, while more evidence is needed regarding SARS-CoV-2 vaccine-induced GD.

The New Entity of Subacute Thyroiditis amid the COVID-19 Pandemic: From Infection to Vaccine

This is a review of full-length articles strictly concerning subacute thyroiditis (SAT) in relation to the SARS-CoV-2 virus infection (SVI) and COVID-19 vaccine (COV) that were published between the 1st of March 2020 and the 21st of March 2022 in PubMed-indexed journals. A total of 161 cases were reported as follows: 81 cases of SAT–SVI (2 retrospective studies, 5 case series, and 29 case reports), 80 respective cases of SAT–COV (1 longitudinal study, 14 case series, 17 case reports; also, 1 prospective study included 12 patients, with 6 patients in each category). To our knowledge, this represents the largest cohort of reported cases until the present time. SAT–SVI was detected in adults aged between 18 and 85 years, mostly in middle-aged females. SAT–COVID-19 timing classifies SAT as viral (synchronous with infection, which is an original feature of SATs that usually follow a viral infection) and post-viral (during the recovery period or after infection, usually within 6 to 8 weeks, up to a maximum 24 weeks). The clinical spectrum has two patterns: either that accompanying a severe COVID-19 infection with multi-organ spreading (most frequent with lung involvement) or as an asymptomatic infection, with SAT being the single manifestation or the first presentation. Either way, SAT may remain unrecognized. Some data suggest that more intense neck pain, more frequent fever, and more frequent hypothyroidism at 3 months are identified when compared with non-SAT–SVI, but other authors have identified similar presentations and outcomes. Post-COVID-19 fatigue may be due to residual post-SAT hypothyroidism. The practical importance of SAT–SVI derives from the fact that thyroid hormone anomalies aggravate the general status of severe infections (particular concerns being tachycardia/arrhythmias, cardiac insufficiency, and ischemic events). If misdiagnosed, SAT results in unnecessary treatment with anti-thyroid drugs or even antibiotics for fever of unknown cause. Once recognized, SAT does not seem to require a particular approach when compared with non-COVID-19 cases, including the need for glucocorticoid therapy and the rate of permanent hypothyroidism. A complete resolution of thyroid hormone anomalies and inflammation is expected, except for cases with persistent hypothyroidism. SAT–COV follows within a few hours to a few weeks, with an average of 2 weeks (no particular pattern is related to the first or second vaccine dose). Pathogenesis includes molecular mimicry and immunoinflammatory anomalies, and some have suggested that this is part of ASIA syndrome (autoimmune/inflammatory syndrome induced by adjuvants). An alternative hypothesis to vaccine-related increased autoimmunity is vaccine-induced hyperviscosity; however, this is supported by incomplete evidence. From what we know so far concerning the risk factors, a prior episode of non-SVI–SAT is not associated with a higher risk of SAT–COV, nor is a previous history of coronavirus infection by itself. Post-vaccine SAT usually has a less severe presentation and a good outcome. Generally, the female sex is prone to developing any type of SAT. HLA susceptibility is probably related to both new types of SATs. The current low level of statistical evidence is expected to change in the future. Practitioners should be aware of SAT–COV, which does not restrict immunization protocols in any case.

Worsening of Graves' ophthalmopathy after SARS-CoV-2 mRNA vaccination

More reports are documenting how vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could represent new external triggers for autoimmune endocrine diseases (AIED) in patients with individual predisposition. We report two cases of Graves' Ophthalmopathy (GO) recrudescence few days after the administration of BNT162B2 (Pfizer-BioNTech) SARS-CoV-2 vaccine. Even if causality relationship cannot be excluded, the development of these events could be explained through immune mediated mechanism such as the autoimmune/inflammatory syndrome induced by adjuvants (ASIA). While further investigations are necessary to improve our knowledge of the underlying pathogenesis of these phenomena, caution may be warranted when vaccinating individuals with known autoimmune diseases.

Relapsed and newly diagnosed Graves’ disease due to immunization against COVID-19: A case series and review of the literature

In addition to genetic factors, environmental factors such as viruses are thought to be triggers in the development of autoimmune thyroid diseases (AITD) such as Graves' disease (GD). In this context, AITD cases that may be associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or immunization have begun to be reported in increasing numbers. Although it is not clear by which pathogenetic mechanisms immunization against coronavirus disease 2019 (COVID-19) triggers the development of AITD, both the potential effect of the adjuvants in the vaccines and the cross-reactivity that can be generated by the molecular similarity of viral particles with mammalian proteins seem to be possible mechanisms. In this article, 7 GD patients consisting of relapsed and newly diagnosed cases following the COVID-19 vaccination were presented. Of these 7 cases, 5 (71.4%) were female, and the median age of the patients was 47 years (range, 31–53). One of the patients was associated with the inactivated COVID-19 vaccine, while the others were associated with the mRNA COVID-19 vaccine. The median post-vaccination symptom onset was 7 days (range, 4–30). Three of the patients had a history of GD and one had a history of Hashimoto's thyroiditis. Rapidly developing Graves' ophthalmopathy was detected in one patient. These cases are cautionary that GD and its extrathyroidal manifestations may develop in a short period after COVID-19 vaccination. When considered together with the literature review, the history of AITD in approximately half of the patients suggests that more attention should be paid to these patients in the post-vaccination period. Nevertheless, multicenter, prospective studies are needed to better understand this possible causal relationship.

COVID-19 vaccine and autoimmunity. A new case of autoimmune hepatitis and review of the literature

Autoimmunity following COVID-19 vaccination has been reported. Herein, a 79-year-old man with clinical and immunological features of autoimmune hepatitis type 1 after ChAdOx1 nCoV-19 vaccination is presented. Clinical manifestations rapidly remitted after the instauration of immunomodulatory management. This case, together with a comprehensive review of the literature, illustrates the association between COVID-19 vaccines and the development of autoimmune conditions.

Thyroid eye disease reactivation associated with COVID-19 vaccination

To describe the presentation of both new-onset and reactivation of thyroid eye disease (TED) following COVID-19 vaccination. Single-institution retrospective case series of patients presenting with symptoms and signs of new or reactivated TED coinciding with recent COVID-19 vaccination. Data collected included patient age, gender, presenting symptoms, ocular history, clinical signs, and interval duration between vaccination and onset of ocular symptoms. Three female patients were identified. All patients were over 18 years of age (range 45–66 years). Patients received either the Moderna or Pfizer COVID-19 vaccine and presented with symptoms of TED within 24 h to 21 days of receiving their first or second dose. None of the patients had previous infections with severe acute respiratory syndrome coronavirus 2. Two patients had a history of inactive TED with stable thyroid function tests: One of these patients had stable disease for at least 15 years and the other had stable disease for 5 years. The third patient had no previous history of thyroid dysfunction or TED and presented with low levels of thyroid-stimulating hormone. All three cases presented with proptosis. In two of three cases, periorbital edema, eyelid retraction, and diplopia were present. None were current smokers. One had prior facial hyaluronic acid filler injections. Symptoms in all cases were improving at 4 to 8 months. While the possibility of unrelated TED flaring concurrently with COVID-19 vaccination exists, questions remain on the effects of the COVID-19 vaccine in patients with autoimmune ophthalmic diseases. Physicians should be aware of this potential association and counsel patients appropriately.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Effect of Inactivated SARS-CoV-2 Vaccines on TRAB in Graves' Disease

BACKGROUND

The ongoing coronavirus disease 2019 (COVID-19) pandemic has forced the development of vaccines. Reports have suggested that vaccines play a role in inducing autoimmune diseases (AIDs). Scattered cases have reported that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines may promote thyroid disease, including Graves' disease (GD). However, the effect of inactivated SARS-CoV-2 vaccine on GD remains unclear. The aim of the present study was to investigate the response of thyrotropin receptor antibody (TRAB) to inactivated SARS-COV-2 vaccines.

METHODS

We conducted a retrospective study to observe the differences in thyroid function and TRAB trends between pre-vaccination (n=412) and post-vaccination (n=231) groups at an interval of 2 months. We then retrospectively observed the differences in serum thyroid function and TRAB levels at 3 months before (n=280), 1 month before (n=294), 1 month after (n=306), and 3 months after (n=250) vaccination. Subsequently, 173 GD patients who were not vaccinated with inactivated SARS-COV-2 vaccines were selected for a prospective study. Thyroid function and TRAB assessment were performed before 3 and 1 months and 1 and 3 months after the first dose of vaccination and were then compared by repeated measures ANOVA to explore their dynamic changes.

RESULTS

A retrospective study preliminarily observed that the trend of TRAB post-vaccination was opposite of that pre-vaccination (p=0.000), serum TRAB levels decreased before vaccination and increased after vaccination. In this prospective study, repeated measures ANOVA indicated significant differences in serum FT3 (p=0.000), FT4 (p=0.000), TSH (p=0.000), and TRAB (p=0.000) levels at different time points before and after vaccination. Serum TRAB levels showed dynamic changes that decreased significantly at 1 month before vaccination (p=0.000), no significant differences at 1 month after vaccination (p=0.583), and reflected an upward trend at 3 months after vaccination (p=0.034). Serum FT3 and FT4 levels showed similar trends to serum TRAB levels before and after vaccination. Instead, the serum TSH levels showed a continuous upward trend over time.

CONCLUSION

Based on the results obtained in both retrospective and prospective studies, we concluded that serum TRAB levels decreased less after inactivated SARS-CoV-2 vaccination and showed an upward trend, which may be related to humoral immunity induced by vaccination.

Thyroid Inconveniences With Vaccination Against SARS-CoV-2: The Size of the Matter. A Systematic Review

After the beginning of COVID-19 vaccination campaigns, several reports of thyroid disease possibly related to the COVID-19 vaccination progressively appeared in the literature, raising the question of whether the thyroid disorder might be a SARS-CoV-2 vaccine complication. The aim of this study was to analyze the data about COVID-19 vaccination and thyroid disease, evaluate the size and quality of related literature, assess the type of these events, and investigate their timing of onset with respect the vaccination. Pubmed/MEDLINE and Cochrane were systematically reviewed until February 2022 to retrieve the largest number of original papers, case reports, and case series articles reporting thyroid disease after SARS-CoV-2 vaccination. Forty-six articles were included with a total of 99 patients aged from 26 to 73 years were described, of whom 74.75% female. Regarding the vaccination received, 49.49% of patients received Comirnaty (Pfizer/BioNTech), 14.14% CoronaVac (Sinovac), 12.12% Vaxzevria (Oxford/Astrazeneca), 11.11% Spikevax (Moderna), 3.03% Ad26.COV2.S (Janssen, Johnson & Johnson), one patient Covaxin (Bharat Biotech) and one patient Convidecia (Cansino). In 7 cases the thyroid disorder developed after the third dose with a combination of different vaccines. Regarding the type of thyroid disorder, 59 were subacute thyroiditis (SAT), 29 Graves' disease (GD), 2 co-occurrence of SAT and GD, 6 painless thyroiditis (PT), and single cases of thyroid eye disease and hypothyroidism associated with mixedema. The timeline between vaccination and thyroid disorder ranged between 0.5 to 60 days, with an average of 10.96 days. Considering the limited follow-up time, a complete remission was reported in most of SAT and PT cases while a persistence was observed in GD. In conclusion, both size and quality of published data about thyroid inconveniences after COVID-19 vaccination are limited; thyroid disorders may occur within 2 months after COVID-19 vaccination; among all thyroid diseases after COVID-19 vaccination, GD and SAT seem to be more frequent.

After the Storm: Ophthalmic Manifestations of COVID-19 Vaccines

Several COVID-19 vaccines have been developed and approved for use around the world from December 2020, to combat the pandemic caused by the novel SARS-CoV-2 virus. Several ophthalmic manifestations of the COVID-19 vaccines have been reported by ophthalmologists. This review was undertaken to recognize, encourage active reporting and determine the pathogenesis and time of appearance for better awareness and understanding of the ophthalmic manifestations of COVID-19 vaccines. A literature search was performed for publications on the ophthalmic manifestations of COVID-19 vaccines between January 1, 2021 and November 7, 2021. 23 case reports, 17 letters to editors, 3 ophthalmic images, 4 brief communications, 4 retrospective cohort studies and 2 case control studies were included. Posterior segment, including the uvea, choroid and retinal vasculature, was most commonly affected and the reported clinical features developed at a median of four days from the time of vaccination. The possible mechanisms include molecular mimicry of the vaccine components with host ocular tissues, antigen-specific cell and antibody-mediated hypersensitivity reactions to viral antigens and adjuvants present in the vaccines. The causal relationship of the ocular signs and symptoms and COVID-19 vaccines has not been established and requires long-term and large multicentre data. Most of the reported manifestations are mild, transient and adequately treated when diagnosed and managed early. The benefits of COVID-19 vaccination outweighs the reported rare adverse events and should not be a deterrent to vaccination.