Subacute Thyroiditis After mRNA Vaccine for Covid-19

Introduction: Subacute thyroiditis is a well-documented clinical condition which typically presents 1-2 weeks after an acute viral illness. Presenting symptoms are classically those of thyrotoxicosis but with associated tenderness in the thyroid. Treatment of acute symptoms is possible and the thyroid function will generally normalize with time. Subacute thyroiditis has rarely been reported after administration of viral vaccinations such as the seasonal flu vaccine. We present a case of subacute thyroiditis which presented after administration of the mRNA COVID-19 vaccine.

Case: Patient is a 42yo female with no past medical history. She received the first dose of the Pfizer/BioNTech mRNA vaccine for COVID-19 on 12/22/20. Five days later, the patient complained of sore throat and palpitations. These symptoms progressed and she was evaluated in an urgent care on 12/31/20 where she was found to have tachycardia. Infectious work-up, including PCR for COVID-19, was negative and she was sent home. She took ibuprofen with some improvement of her symptoms. The following day she went to the ED; she was found to have a heart rate in the 130s with sinus tachycardia on EKG. Thyroid function testing was done which revealed TSH <0.01, fT4 4.58, fT3 11.8. Her TPO antibody was <28 and inflammatory markers were elevated including sed rate of 62. The patient was prescribed prednisone 40mg daily and propranolol 20mg as needed for symptoms. She reports rapid improvement of symptoms with prednisone. On 1/21/20, thyroid function showed TSH <0.01, fT4 down to 3.2, tT3 normal at 135. Thyroglobulin was elevated at 140.8 with negative thyroglobulin antibody, TRAb and TSI. Her inflammatory markers had decreased with sed rate of 26 and normal C-reactive protein. She had improved symptoms.

Discussion: Cases of subacute thyroiditis are most commonly associated with upper respiratory viruses but cases have been reported with traditional inactivated viral vaccines or live-attenuated vaccines such as those for annual influenza. We present the case of a 42-year-old female who has presented with a classic case of subacute thyroiditis which occurred in the time frame after receiving the Pfizer mRNA vaccine for COVID-19. Research has been ongoing for decades regarding development of mRNA vaccines but the mRNA vaccines for the SARS-CoV-2 virus have been the first to be widely distributed to the general population. Thyroiditis has not been reported as a common side effect but the cross recognition between the coronavirus spike protein targeted with the mRNA vaccine and healthy thyroid cell antigens exists as evidenced by this case.

Sources: 1. Prummel M, Strieder T, Wiersinga WM. The environment and autoimmune thyroid diseases. Eur J Endocrinol. 2004;150:605-618. Altay FA, Guz G, Altay M. 2. Subacute thyroiditis following seasonal influenza vaccination. Hum Vaccin Immunother. 2016;12(4):1033-1034.

Storm’s a Brewing

Intro: Thyroid storm is an often feared but overall rare complication of untreated hyperthyroidism. This severe presentation of thyrotoxicosis has multiple different treatment modalities with actual treatment directed by the patient’s clinical course. We present the case of a 34-year-old male who presents in thyroid storm. Case: A male presented to the emergency department in southern Arizona in July with complaint of dizziness and tachycardia after working outside in the sun all day. He was rehydrated with symptomatic improvement but had continued tachycardia. The patient refused admission and left the emergency department prior to his thyroid function tests resulting with a TSH of <0.02 and FT4 of 7.43. He had no apparent follow-up or further symptoms until he presented back to the emergency department approximately one year later at age 34. He presented the second time with shortness of breath and palpitations and was found to have atrial fibrillation with rapid ventricular rate >200, a TSH <0.02, and TSH of 6.59. He was tachypneic, but his temperature and blood pressure were within normal limits. He had a CTA of the chest that showed bilateral pulmonary infiltrates. He was started on intravenous metoprolol and diltiazem without resolution of his tachycardia, so an amiodarone drip was started. Hours later, the patient became hemodynamically unstable and went into cardiac arrest. Return of spontaneous circulation was obtained and the patient was intubated with post-arrest cooling protocol initiated. The patient was clinically diagnosed with thyroid storm, which was supported by an elevated Burch-Wartofsky score. Post-arrest treatment of thyroid storm was complicated by acute liver failure, systolic heart failure with ejection fraction <20%, and persistent tachycardia. The patient was treated with high dose methimazole, propranolol, potassium iodine drops, corticosteroids, and cholestyramine. Surgery was considered given the slow progression of medical treatment but no pursued due to cardiovascular risk. Plasmapheresis was considered but not available. The patient’s thyroid function was followed daily and improved over a week despite persistent tachycardia and delirium. Eventually, the patient was discharged home with daily methimazole 20mg and planned outpatient follow-up for definitive therapy. Discussion: This patient presented to the ED with evidence of thyrotoxicosis that was untreated for one year prior to returning with thyroid storm. This illustrates the ability of a young, otherwise healthy patient to compensate for a prolonged period with relatively few symptoms prior to decompensating. This also shows the importance of having a system in place to catch abnormal laboratory results even if the patient is no longer present in the facility; a project has already been completed to catch abnormal thyroid function testing at our facility in the future.

MON-908 Carcinoid Causing Catastrophic Calcemia

Intro: Carcinoid tumors are rare, slow growing, indolent neuroendocrine tumors typically originating from enterochromaffin in the gastrointestinal tract and bronchopulmonary tree₁. While often found to be secreting serotonin, many different secretory products have been described₂. We present the case of a patient with refractory hypercalcemia due to a carcinoid tumor producing parathyroid hormone related peptide (PTHrP). Case: A 65-year-old male was found to have hypercalcemia of 14.7 mg/dL after presenting for nausea and vomiting. He was treated with Zolendronic acid and intravenous (IV) fluids as initial work-up revealed an appropriately suppressed parathyroid hormone level, no monoclonal spike, and a PTHrP that was dramatically elevated. He refused further work-up initially but was admitted two months later for persistent severe hypercalcemia. Computed tomography imaging showed innumerable liver lesions. Histologic analysis of the largest liver lesion was consistent with carcinoid tumor. For the next two years, he was managed outpatient with Pamidronate, Denosumab, and Sandostatin, along with two liver embolizations. Control of serum calcium levels became more difficult and he had multiple hospitalizations for symptomatic hypercalcemia until chemotherapy, Sunitinib, was initiated. Calcium levels normalized for one year after starting Sunitinib prior to onset of suspected medication-induced pancreatitis. He was switched to Everolimus but did not respond to that and was readmitted mere weeks later for symptomatic hypercalcemia and a combination of Folinic acid, Fluorouracil, and Oxaliplatin (Folfox) was started. He continued to get frequent bisphosphonates and IV fluids along with Folfox but several months later he stopped responding to all medical options. His calcium level climbed to 19.9mg/dL and he underwent a technically complicated surgical procedure in which significant tumor burden was removed from his liver. Since surgery, the patient has remained normocalcemic without additional medical therapy. Discussion: Carcinoid tumors are uncommon with reported incidence of 40 per one million people₂. PTHrP is most commonly produced by squamous cell lung cancer, renal cell cancer, gynecologic cancers, and lymphoma₃. Carcinoid tumors producing PTHrP with resultant hypercalcemia is rare with a few cases reported in literature₄. Our patient had a complex treatment course including IV fluids, anti-resorptive agents, somatostatin analogs, liver embolization, chemotherapeutic agents, and eventual surgical debulking. Surgical intervention is not commonly required for carcinoid tumors₅. This patient had a rare tumor, producing an uncommon hormone, and required extensive treatment. This case shows the importance of a multidisciplinary approach in patients with hypercalcemia secondary to carcinoid tumors but refractory to traditional therapy.

Bone mineral content and bone density is lower in adolescents with type 1 diabetes: A brief report from the RESISTANT and EMERALD studies

To understand the effect of type 1 diabetes (T1D) on bone mineral content (BMC) and bone density (BMD), we studied 125 T1D adolescents and 80 pubertal stage matched controls. T1D was associated with lower whole-body BMC and BMD compared to controls, even when adjusted for age, sex and sex hormones.

Evolution of the melanocortin-2 receptor in tetrapods: studies on Xenopus tropicalis MC2R and Anolis carolinensis MC2R

The tetrapods are a diverse assemblage of vertebrates, and that diversity is reflected in the sequences of tetrapod melanocortin-2 receptors (MC2Rs). In this review, the features common to human (mammal), Gallus gallus (bird), Anolis carolinensis (reptile), and Xenopus tropicalis (amphibian) MC2Rs in terms of ligand selectivity, requirements for interaction with MRAP1, and the effects of alanine substitutions to three amino acid motifs in the ligand hACTH(1-24) are discussed. Analysis of the effects of alanine substitutions to the H(6)F(7)R(8)W(9) and the K(15)K(16)R(17)R(18)P(19) motifs of hACTH(1-24) indicated that activation of A. carolinensis MC2R and X. tropicalis MC2R was more adversely affected by alanine substitutions at these positions as compared to the response of human MC2R to these same analogs. Furthermore, single alanine substitutions in the G(10)K(11)P(12)V(13)G(14) motif of hACTH(1-24) had negative affects on activation of both A. carolinensis MC2R and X. tropicalis MC2R that were not observed for human MC2R. The implications of responses to the various analogs of hACTH(1-24) in terms of the mechanism for mediating the activation of these various tetrapod melanocortin-2 receptors are discussed.