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Fallahi P, Elia G, Ragusa F, Paparo SR, Patrizio A, Balestri E, Mazzi V, Benvenga S, Varricchi G, Gragnani L, Botrini C, Baldini E, Centanni M, Ferri C, Antonelli A, Ferrari SM. Thyroid Autoimmunity and SARS-CoV-2 Infection. J Clin Med 2023; 12:6365. [PMID: 37835009 PMCID: PMC10573843 DOI: 10.3390/jcm12196365] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiological culprit of COronaVIrus Disease 19 (COVID-19), can enter the cells via the angiotensin-converting enzyme 2 (ACE2) receptor, which has been found in several tissues including in endocrine organs, such as the ovaries, testes, pancreas, and thyroid. Several thyroid disorders have been associated with SARS-CoV-2 infection [subacute thyroiditis (SAT), thyrotoxicosis, and non-thyroidal illness syndrome (NTIS)] and, in part, they are believed to be secondary to the local virus replication within the gland cells. However, as documented for other viruses, SARS-CoV-2 seems to interfere with several aspects of the immune system, inducing the synthesis of autoantibodies and triggering latent or new onset autoimmune disease (AID), including autoimmune thyroid disease (AITD), such as Hashimoto Thyroiditis (HT) and Graves' disease (GD). Several mechanisms have been hypothesized to explain this induction of autoimmunity by SARS-CoV-2 infection: the immune system hyper-stimulation, the molecular mimicry between the self-antigens of the host and the virus, neutrophils extracellular traps, and finally, the virus induced transcriptional changes in the immune genes; nonetheless, more evidence is needed especially from large, long-term cohort studies involving COVID-19 patients, to establish or reject this pathogenetic relationship.
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Affiliation(s)
- Poupak Fallahi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (P.F.); (S.R.P.); (L.G.)
| | - Giusy Elia
- Department of Surgery, Medical and Molecular Pathology and of Critical Area, University of Pisa, 56126 Pisa, Italy; (G.E.); (F.R.); (E.B.); (V.M.); (C.B.)
| | - Francesca Ragusa
- Department of Surgery, Medical and Molecular Pathology and of Critical Area, University of Pisa, 56126 Pisa, Italy; (G.E.); (F.R.); (E.B.); (V.M.); (C.B.)
| | - Sabrina Rosaria Paparo
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (P.F.); (S.R.P.); (L.G.)
| | - Armando Patrizio
- Department of Emergency Medicine, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy;
| | - Eugenia Balestri
- Department of Surgery, Medical and Molecular Pathology and of Critical Area, University of Pisa, 56126 Pisa, Italy; (G.E.); (F.R.); (E.B.); (V.M.); (C.B.)
| | - Valeria Mazzi
- Department of Surgery, Medical and Molecular Pathology and of Critical Area, University of Pisa, 56126 Pisa, Italy; (G.E.); (F.R.); (E.B.); (V.M.); (C.B.)
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine—Endocrinology, University of Messina, 98122 Messina, Italy;
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, 98122 Messina, Italy
- Interdepartmental Program of Molecular & Clinical Endocrinology and Women’s Endocrine Health, University Hospital Policlinico “G. Martino”, 98124 Messina, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, 80131 Naples, Italy;
- Center for Basic and Clinical Immunology Research, University of Naples Federico II, 80131 Naples, Italy
- World Allergy Organization Center of Excellence, University of Naples Federico II, 80131 Naples, Italy
- Institute of Experimental Endocrinology and Oncology “Gaetano Salvatore”, National Research Council, 80131 Naples, Italy
| | - Laura Gragnani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (P.F.); (S.R.P.); (L.G.)
| | - Chiara Botrini
- Department of Surgery, Medical and Molecular Pathology and of Critical Area, University of Pisa, 56126 Pisa, Italy; (G.E.); (F.R.); (E.B.); (V.M.); (C.B.)
| | - Enke Baldini
- Department of Experimental Medicine, “Sapienza” University of Rome, 00185 Rome, Italy;
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Endocrinology Section, ‘‘Sapienza’’ University of Rome, 00185 Rome, Italy;
- Endocrine Unit, Azienda Unità Sanitaria Locale (AUSL) Latina, 04100 Latina, Italy
| | - Clodoveo Ferri
- Rheumatology Unit, School of Medicine, University of Modena and Reggio Emilia, 41100 Modena, Italy;
- Rheumatology Clinic ‘Madonna Dello Scoglio’ Cotronei, 88836 Crotone, Italy
| | - Alessandro Antonelli
- Department of Surgery, Medical and Molecular Pathology and of Critical Area, University of Pisa, 56126 Pisa, Italy; (G.E.); (F.R.); (E.B.); (V.M.); (C.B.)
| | - Silvia Martina Ferrari
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
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Gherlan G, Gheorghiu M, Constantin C, Enyedi M, Baloseanu N, Tanasie D, Gherlan I. Management of thyroiditis in the context of Covid-19: cause-effect and beyond. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2023; 19:471-479. [PMID: 38933252 PMCID: PMC11197832 DOI: 10.4183/aeb.2023.471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Background The COVID-19 pandemic hit the world in late 2019, and by 2020, everyone was affected. Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) belongs to the beta-coronavirus genre and uses the angiotensin-converting enzyme 2 (ACE2) receptor to penetrate cells. Thyroid cells are rich in such receptors. Therefore, this gland is frequently involved alongside other organs in the COVID-19 disease. Aim To describe COVID-19 inflammation and, eventually, dysregulations of normal thyroid function in a case series of patients diagnosed in a tertiary endocrinology care centre. Patients and Methods We described subacute thyroiditis cases related to COVID-19 infection or vaccination against SARS-CoV2 infection (clinical manifestations and evolution). We also reviewed the literature data regarding COVID-19 infection or vaccination implications in thyroid pathology. Results The literature describes two types of thyroid involvement in SARS-CoV2 infection or vaccination: subacute thyroiditis (SAT) and non-thyroidal illness syndrome (NTIS). In our case series, 5 patients (3 males), aged 41-54 years, developed the classical clinical manifestation of SAT related to COVID-19 infection (3 patients, concomitantly to upper respiratory infection or a few weeks apart) or anti-SARS-CoV2 ARNm vaccination (1-2 weeks after the vaccine administration). Clinical, laboratory and imaging findings and the evolution (steroid anti-inflammatory treatment used in 4/5 cases) were unremarkable compared to other SAT etiologies. Conclusion We found no differences between the "typical" viral and post-COVID-19 SAT regarding clinical presentation, severity, response to treatment, and thyroid function alteration. The only remarkable difference is the association of SAT with anti-SARS-CoV2 ARNm vaccination.
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Affiliation(s)
- G.S. Gherlan
- “Carol Davila” University of Medicine and Pharmacy
- “Dr Victor Babes” Clinical Hospital of Infections and Tropical Diseases
| | - M.L. Gheorghiu
- “Carol Davila” University of Medicine and Pharmacy
- “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania
| | - C. Constantin
- “Carol Davila” University of Medicine and Pharmacy
- “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania
| | - M. Enyedi
- “Carol Davila” University of Medicine and Pharmacy
| | - N. Baloseanu
- “Dr Victor Babes” Clinical Hospital of Infections and Tropical Diseases
| | - D.I. Tanasie
- “Carol Davila” University of Medicine and Pharmacy
| | - I. Gherlan
- “Carol Davila” University of Medicine and Pharmacy
- “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania
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Ciftel S, Tüzün Z. SUBACUTE THYROIDITIS FOLLOWING SARS-COV-2 VACCINATION: AN AUTOIMMUNE/INFLAMMATORY SYNDROME INDUCED BY ADJUVANTS (ASIA SYNDROME). ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2023; 19:390-395. [PMID: 38356966 PMCID: PMC10863968 DOI: 10.4183/aeb.2023.390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Context Subacute thyroiditis, a manifestation of Autoimmune/inflammatory syndrome induced by adjuvants that may develop after vaccination. Objective The aim of this study is to determine the importance of vaccination against COVID-19 in the etiology of subacute thyroiditis. Design This case reports/series is an observational, descriptive research design. Subjects and Methods Five of the thirty patients who applied to our clinic with subacute thyroiditis in the last 6 months had a history of inactivated and mRNA vaccines in the last four weeks, after exclusion of infection and comorbidities. We present three cases of mRNA-based vaccination and two cases of inactive SARS-CoV-2 vaccination that met ASIA criteria. Results Our findings suggest that subacute thyroiditis may be a complication of vaccination against COVID-19. Conclusion Vaccine administration may led to autoimmune manifestation induction as well as autoantibody production. Adjuvant-induced autoimmune/inflammatory syndrome, an abnormal autoimmune response as a result of exposure to an adjuvant such as vaccine, appears likely in our cases.
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Affiliation(s)
- S. Ciftel
- Erzurum Health Science University, Faculty of Medicine –Internal Medicine, Endocrinology
| | - Z. Tüzün
- “Ataturk” University, Faculty of Medicine–Rheumatology, Erzurum, Turkey
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Rushing MW, Rebolledo MA, Lahoti A, Alemzadeh R. Acute febrile illness in a teenage female with history of Graves' disease. Oxf Med Case Reports 2023; 2023:omad050. [PMID: 37260732 PMCID: PMC10228105 DOI: 10.1093/omcr/omad050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/08/2023] [Accepted: 03/31/2023] [Indexed: 06/02/2023] Open
Abstract
Thyroid storm is a rare, life-threatening condition that is usually precipitated by Graves' disease in children and adolescents. COVID-19 (SARS-CoV-2) can cause multisystem inflammatory syndrome in children (MIS C), which shares some features of Graves' disease. We present a case of acute thyroid storm following SARS-CoV-2 infection in a 16-year-old female with poorly controlled Graves' disease. She initially presented to the emergency department for fever and palpitations. Initial laboratory results suggested thyroid storm, for which she was started on propranolol. She remained tachycardic with new gallop rhythm on exam. An echocardiogram demonstrated a depressed left ventricular ejection fraction and mild pulmonary hypertension. Her SARS-CoV-2 antibodies were positive. She was started on intravenous immunoglobulin for suspected MIS-C. She responded to combined treatment of thyroid storm and MIS-C. She was discharged home on propranolol, methimazole, cholestyramine and aspirin.
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Affiliation(s)
- Mark W Rushing
- Correspondence address. Department of Pediatrics, Division of Pediatric Cardiology, The University of Tennessee Health Science Center, Division of Pediatric Cardiology, Faculty Office Building, 9 N. Dunlap St., 3rd floor, Memphis, TN 38103, USA. Tel: 901.287.6034; Fax: 901.287.5062; E-mail:
| | - Michael A Rebolledo
- Department of Pediatrics, Division of Pediatric Cardiology, The University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
| | - Amit Lahoti
- Department of Pediatrics, Division of Pediatric Endocrinology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Ramin Alemzadeh
- Department of Pediatrics, Division of Pediatric Endocrinology, The University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
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Radulescu V, Dumitrascu A, Alexandrescu D, Badiu C. ZOSTER TRIGGERS IN GRAVES OPHTHALMOPATHY. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2023; 19:267-268. [PMID: 37908886 PMCID: PMC10614578 DOI: 10.4183/aeb.2023.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Affiliation(s)
- V. Radulescu
- “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania
| | - A. Dumitrascu
- “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania
| | - D Alexandrescu
- “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania
| | - C. Badiu
- “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Dept. of Endocrinology, Bucharest, Romania
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Abstract
Breakdown of self-tolerance to thyroid antigens (thyroperoxidase, thyroglobulin and the thyrotropin-receptor) is the driver of thyroid autoimmunity. It has been suggested that infectious disease might trigger autoimmune thyroid disease (AITD). Involvement of the thyroid has been reported during severe acute respiratory syndrome virus 2 (SARS-CoV-2) infection, in the form of subacute thyroiditis in subjects with mild coronavirus disease 19 disease (COVID-19) and of painless, destructive thyroiditis in hospitalized patients with severe infection. In addition, cases of AITD, both Graves' disease (GD) and Hashimoto's thyroiditis (HT), have been reported in association with (SARS-CoV-2) infection. In this review, we focus on the relationship between SARS-CoV-2 infection and occurrence of AITD. Nine cases of GD strictly related to SARS-CoV-2 infection and only three cases of HT associated to COVID-19 infection have been reported. No study has demonstrated a role of AITD as a risk factor for a poor prognosis of COVID-19 infection.
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Affiliation(s)
- Alessandro Brancatella
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Nicola Viola
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Ferruccio Santini
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Francesco Latrofa
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy.
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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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