Endocrine Abstracts

Introduction: There is evidence on the association of subacute thyroiditis (SAT) and SARS-CoV-2 infection, the first case report being described in a young woman back in July 2020 (1). Multisystemic inflammatory syndrome in adults (MIS-A) is a rare complication of SARS-CoV-2, usually 2 to 12 weeks after initial infection. The development of Graves disease after SAT is rare, with approximately 31 reported cases, of which only 5 occurring in men (2). We present the case of a young patient with thyrotoxicosis following SARS-CoV-2 infection.

Case Report: A 45-year-old male patient presented to our hospital with weight loss, palpitations and irritability. The medical history revealed SARS-CoV2 infection 3 months prior to presentation and an acute cytomegalovirus hepatitis 2 years ago. The patient was tachycardic, normotensive and afebrile. The laboratory tests revealed markedly elevated acute inflammatory markers: fibrinogen - 1240 mg/dl, CPR - 25.02 mg/dl, cholestasis: GGT - 914 U/l, ALP - 325 U/l and thyrotoxicosis: TSH - 0.0013 microUI/ml, freeT4 - 40.5 pmol/l, with negative thyroid stimulating hormone receptor antibody (TRAb). Screening for obstructive cholestasis and liver infectious disease was negative. Ultrasound examination indicated a diffuse enlargement of thyroid gland with multiple hypoechoic areas in the left thyroid lobe, suggestive for subacute thyroiditis. Treatment with intravenous dexamethasone 24 mg per day for 1 week in combination with methimazole 20 mg per day was started. Within the first week, the patient’s condition improved with significant decrease of freeT4 and serum cholestasis markers and normalization of inflammatory markers. The patient was discharged with methylprednisolone 16 mg every two days and methimazole 15 mg per day. At 2-weeks follow-up, the thyroid function was normal under treatment, but TRAb had a positive value.

Conclusion: Our patient’s presentation was atypical for SAT with no pain in the anterior surface of the neck and no fever. Given the late positivity of TRAb, we can consider the hypothesis that thyrotoxicosis emerged due to Graves disease and the markedly elevated acute inflammatory markers were explained by a multisystem inflammatory syndrome in adults. Clinicians should be aware of the potential development of MIS-A as a sequela of COVID-19. Also, there is a rare possibility that the subacute thyroiditis triggered the development of Graves disease.

References: (1) Brancatella A et al, Subacute thyroiditis after Sars-COV-2 infection. J Clin Endocrinol Metab. 2020;105(7):2367-2370. (2) Souad Al-Bacha et al, Graves’ Disease Following Subacute Thyroiditis in a Chinese Man, AACE Clinical Case Reports, 2021.