Endocrine Abstracts

Introduction: SARS-CoV2 infection or vaccination against SARS-CoV2 has been linked to the onset or recurrence of Autoimmune and subacute thyroiditis resulting in thyroid dysfunction.

Case: We describe a case of Thyroid eye disease temporally associated with SARS-CoV 2 infection in a 48 year old female with a one-year history of subclinical hypothyroidism without interval thyroid hormone replacement or SARS-CoV2 vaccination. Two months following PCR confirmed SARS-CoV 2 infection, the patient presented with eye irritation and oedema. Direct ophthalmological assessment led to a diagnosis of thyroid eye disease. CT orbit confirmed bilateral proptosis with increased intraorbital fat. TSH was 0.01 mIU/l (0.27-4.2) and FT4 18 pmol/l (12-20). Carbimazole 10 mg BD was commenced as she complained of palpitations, heat intolerance and tremor. TFTs three months later indicated T3-thyrotoxicosis (TSH <0.01 mIU/l (0.35-4.94), FT4 14.3 pmol/l (9.0-20.0) Free T3 6.3 pmol/l (2.6-4.9)) with elevated TSH Receptor Antibody 3.5 U/l (0-0.4) in keeping with a diagnosis of Grave’s Disease. The patient was referred to Endocrinology for clinical assessment. At that assessment, nine months following eye symptom onset, the patient was clinically and biochemically euthyroid on Carbimazole 5 mg BD (TSH 3.24 mIU/l (0.35-4.94), FT4 11.8 pmol/l (9.0-20.0), Free T3 3.9 pmol/l (2.6-4.9), Anti TPO 108.1 IU/ml (<5.6)). She was an ex-smoker of 2 years with no family history of autoimmunity. Of note the patient reported L-thyroxine replacement until 4 years prior to presentation. Review of available TFTs one year prior, off L-thyroxine, showed TSH 8.7 mIU (0.27-4.2), T4 13.4 pmol/l (12-22), thyroid antibodies unavailable. Mild non-tender goitre was evident on exam with palpebral oedema and conjunctival injection without exophthalmos or lid retraction. Carbimazole was stopped. Although still troubled by eye irritation the patient remains clinically and biochemically euthyroid on review 12 months following onset of eye symptoms (TSH 2.85 mIU/l (0.35-4.94), FT4 12.8 pmol/l (9.0-20.0), Free T3 4.5 pmol/l (2.6-4.9) with reducing titres of TSH Receptor Antibody 1.2 U/l ((0-0.4)).

Conclusion: There have been numerous published cases of new or recurrent Graves’ disease and Subacute thyroiditis following SARS-CoV2 infection. In our case, the rapid response to antithyroidal medications and predominant ophthalmic symptoms perhaps point to a dual diagnosis of acute thyroiditis and Graves’ Eye Disease. The case is also interesting in that she had a history of sub-clinical hypothyroidism. Should she become hyperthyroid again, thyroid scintigraphy would be beneficial. Clinicians should remain cognisant of the effect of SARS-CoV2 infection on thyroid dysfunction.