ABSTRACT
Introduction: SARS-COV-2, causing the COVID-19 pandemic, had a disease spectrum affecting multiple organs since its emergence in 2019. There is an association between COVID-19 and thyroid disease. Multiple vaccines had been approved for SARS-COV-2. Despite their safety profile, adverse effects have been reported. An association between thyrotoxicosis after the vaccine has been reported. But COVID-19 vaccine is very rare to precipitate a thyroid storm. Case Description: 29-year-old gentleman, presented to Emergency Department (ED) complaining of shortness of breath for 5 days, increasing in severity. He had a cough with whitish sputum, no fever or chest pain. He had palpitations and 10 kg weight loss, for 6 months. Five days prior to the presentation he received the second dose of the BNT162b2 vaccine (Pfizer-BioNTech COVID -19 vaccine) Physical examination: the vital signs showed tachycardia 175 beat/minute with an irregular pulse, otherwise unremarkable, he was conscious alert and oriented to time place and person, there was bilateral mild exophthalmos and diffuse soft goiter. Chest exam showed bilateral coarse basal crackles. He has bilateral pitting edema of the lower limbs. Blood investigation was remarkable for TSH < 0.01 (0.3-4.5 mIU/L), FT3 12.6 (3.6-7.4 pmol/L), FT4 48.5 (11-23.5 pmol/L) and TSH receptor antibodies (TRAB) 34, Positive > 1.75 IU/L. Electrocardiography showed atrial fibrillation with a rapid ventricular response. Echocardiography showed reduced ejection fraction (40%) with moderate global hypokinesia. The patient was admitted under MICU care as thyroid storm (Bursh-Wartosfsky score 50/140) secondary to Graves’s disease and precipitated by COVID 19 vaccine. He was started on Propylthiouracil 200 mg every 4 hours, hydrocortisone 100 mg every 8 hours, Lugol’s solution 10 drops every 8 hours, cholestyramine 4 gm every 6 hours, and metoprolol 12.5 mg every 12 hours, the dose of metoprolol increased gradually to avoid worsening of heart failure. The patient’s condition was improving, he was switched from propylthiouracil to carbimazole 20 mg twice daily, and after a few days, he was stable and discharged home on carbimazole and metoprolol. The patient didn’t attend the endocrine clinic for follow-up as he traveled back to his home country. Discussion: The association between thyrotoxicosis and the COVID-19 vaccine is reported in the literature. Very rarely COVID-19 vaccine can precipitate thyroid storm in a patient with Graves’s disease. The immune system activation after the vaccine possibly leads to a decompensated state in this patient with existing hyperthyroidism.