A Case of Primary Biliary Cirrhosis With New Onset Hyperthyroidism and Supratherapeutic INR

Introduction: Hyperthyroidism is known to increase catabolism of vitamin-K-dependent clotting factors (II, VII, IX, X) and increase the response of vitamin K antagonists, usually warfarin. Primary biliary cirrhosis (PBC) has been associated with thyroid dysfunction (TD), especially with autoimmune thyroid disease. In the below case, a patient with known PBC on warfarin is found to have severely elevated INR related to new-onset hyperthyroidism with clinical consequences of hemorrhage including upper GI bleed. Case Description/Methods: A 64-year-old female with PBC and antiphospholipid antibody syndrome on warfarin was admitted for hemorrhagic epiglottitis requiring emergency intubation and supratherapeutic INR. Her PBC was diagnosed as stage II on biopsy 23 years ago and has remained clinically stable on ursodiol therapy. On presentation, the patient was tachycardic, tachypneic, and had O2 saturations <90% on HFNC prior to intubation. Physical exam significant for larger goiter with diffuse upper airway swelling. She was admitted and found to have COVID-19 infection, INR .16.0 and PT>200.0 (limit of lab), WBC of 22.8, and lactate of 2.5. LFTs WNL aside from albumin of 2.0. TSH was <0.0017 (limit of lab) and free T4 of 3.4, free T3 of 5.3. TSH receptor antibody (TRAB) and thyroid stimulating immunoglobulin (TSI) levels were normal. Her last TSH was normal a year ago. CTA chest found a 5.7cm heterogeneous, partially calcified superior mediastinal mass consistent with multinodular thyroid goiter. Patient was initially given prothrombin complex concentrate and vitamin K with correction of INR over the following few days. She was extubated and started on methimazole. During the hospital course, she was found to have coffee ground emesis for which an EGD was done with findings of non-bleeding gastric ulcer (Forrest Class IIc) and LA Grade D esophagitis with adherent clot and bleeding for which hemostatic spray was applied. Patient was discharged a few days later following resumption of warfarin and on pantoprazole and methimazole. Discussion(s): The above case demonstrates a rare case of PBC and new-onset hyperthyroidism due to multinodular thyroid goiter causing significantly elevated INR in the setting of warfarin use with hospital course complicated by GI bleed. PBC is associated with TD - hyperthyroidism, hypothyroidism, and thyroid cancer. Hyperthyroidism is less commonly associated with PBC compared to other TDs but should be considered especially with a finding of elevated INR.

Silent Thyroiditis as a Complication of Severe Acute Respiratory Syndrome Coronavirus 2 Vaccine

Introduction: Silent autoimmune thyroiditis, a type of chronic autoimmune thyroiditis, as an adverse effect of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination is infrequently reported in the literature. We hereby describe a case of silent thyroiditis followed by Grave's orbitopathy after vaccination against SARS-CoV2. Case Description: An 84-year-old male presented to clinic with a 10-pound weight loss with no other symptoms of hyperthyroidism, no personal history of thyroid illnesses, or recent viral infections. He had normal thyroid function 3 months prior to presentation. He had received 3 doses of SARS-CoV2 Pfizer-BioNTech vaccine with the last dose 5 months prior to presentation. Thyroid exam was normal. Laboratory testing revealed thyroid stimulating hormone (TSH) level of 0.005 IU/ml (0.45-4.5 IU/ml), total T4 14.4 g/dl (4.5-12.1 g/dl), and total T3 1.22 nmol/l (0.6-1.81 nmol/l). Thyroid Ultrasound revealed a heterogeneous atrophic thyroid gland with no nodules or hypervascularity. He was started on Methimazole by primary care provider. Four months later, he was seen in the Endocrinology clinic and reported no hyperthyroidism symptoms. His TSH level at that time was 65.9 IU/ml, free T4 0.47 ng/dl (normal: 0.82-1.77 ng/dl), total T3 level 75 ng/dl (normal: 71-180 ng/dl), thyroid stimulating immunoglobulin 2.05 IU/l (0-0.55 IU/L), thyrotropin receptor antibody level 2.8 (0-1.75). Methimazole was discontinued. At 6 months after initial presentation laboratory testing showed TSH 5.010 IU/ml, free T4 1.2 ng/dl, thyroid peroxidase antibody of 148 IU/ml (normal 0-34 IU/ml), thyroglobulin antibody 131.6 IU/ml (normal 0.0-0.9 IU/ml). He was diagnosed with silent autoimmune thyroiditis. A few weeks later, the patient presented to an ophthalmologist with bilateral eye bulging and impaired vision. He was diagnosed with acute Graves' orbitopathy and started on pulse-dose of intravenous Methylprednisolone 250 mg twice daily and urgently referred to a tertiary ophthalmology center for teprotumumab infusion. His thyroid function tests were normal at that time on no thyroid medications. Discussion(s): The underlying mechanisms of thyroid impairment following SARS-CoV2 vaccination are not completely understood. There is a role of molecular mimicry between SARS-CoV2 antigens and thyroid antigens that may help to hasten the emergence of autoimmunity in vulnerable individuals. Our patient developed multiple thyroid-related antibodies following vaccination. Silent painless thyroiditis is a self-limiting condition, characterized by temporary thyrotoxicosis, followed by a brief period of hypothyroidism and then a complete return to normal thyroid function. A radioactive iodine uptake scan can help differentiate between the different causes of thyrotoxicosis in the acute thyrotoxic phase. Development of severe Graves orbitopathy following silent autoimmune thyroiditis after SARS COV2 vaccination has not been previously reported.Copyright © 2023

Thyroid Adverse Events after SARS-CoV-2 Vaccination

Introduction: Subacute thyroiditis and autoimmune thyroiditis are known complications of COVID-19 infection. With the development of SARS-CoV-2 vaccine, new cases of thyroiditis following vaccination have been reported. In accordance, we report on a series of patients who present with hyperthyroidism, elevated TSH receptor activating antibodies, concerning for activation of Graves disease after receiving SARS-Cov-2 messenger RNA (mRNA) vaccine. This association underpins the possible immune modulation affecting the presentation of autoimmune thyroiditis post vaccination. Case Description: We describe four patients who present with symptoms of hyperthyroidism after receiving SARS-CoV-2 mRNA vaccine. All were females, median age 49 (range 44-59). Two patients presented with de novo hyperthyroidism 25-29 days following SARS-CoV-2 mRNA vaccine. Two patients have previously had diagnosed Graves disease in remission for longer than 3 years and presented after 40-60 days after receiving SARS-CoV-2 mRNA vaccine. All four patients had TSH receptor antibodies positive (range 6.21-11.87IU/L) Discussion: Although vaccines are one of the most successful medical advances clarifying associated conditions and risks is of interest to practicing physicians. It is not known if these 4 cases of Graves disease were diagnosed coincidentally following SARS-CoV-2 vaccine and association between this vaccine and autoimmune manifestations remains to be further investigated. This report adds information to current knowledge and understanding of autoimmune manifestations following SARS-CoV-2 vaccine.Copyright © 2023

Side Effects of the Sinopharm/BBIBP COVID-19 Vaccine among Iranian Healthcare Workers: A Gender Assessment

Background: Since the outbreak of COVID-19, vaccination has been considered as an important measure against it. Side effects have always been an inseparable component of vaccination, which in this study, Sinopharm vaccine, its side effects and the differences of their manifestation amongst men and women have been investigated. Objective(s): This study aimed to compare the side effects of the Sinopharm vaccine among men and women working in some medical centers in Tehran, Iran. Method(s): This cross-sectional descriptive-analytical study on 890 healthcare workers of 7 medical centers in Tehran within 2 months, from late June to late August 2021. The samples were selected by the complete enumeration method, and the required data were collected using a questionnaire. Only those who received the Sinopharm vaccine at least 10 days before the study were included. Result(s): Of 890 participants, 22.96% and 77.30% were women and men, respectively, and 65.8% of women and 78.1% of men were in the age range of 20-29 years. It was revealed that 74.75% of women and 26.16% of men had at least one side effect. The incidence of at least one side effect was significantly higher in women than in men (P<0.001). It was also found that 12 side effects were significantly higher in women than in men. Most men and women had side effects within the first 24 h after vaccination. There was no significant difference in taking therapeutic measures to reduce or minimize the post-vaccination complications between men and women;however, 9.4% of men and 27.2% of women reported a decline in their ability to perform daily activities as they were unable to do their everyday tasks the day after vaccination which was significantly different between the two groups (P<0.001). Conclusion(s): The results showed that the occurrence rate of side effects after receiving the Sinopharm vaccine was significantly higher in women than in men. Moreover, women were significantly less able to perform daily routines than men.Copyright © 2022, Author(s).

Post-Covid Neurological Effects Can Be Misguiding In Cases Of The Recovered Patients - A Case Study

In 2019, a new virus-A novel virus, COVID-19, bought disaster across the globe. The people were in great panic, death tolls crossed millions in number. Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus. It is a debilitating disease-causing post covid effects too. Many of the cases have not yet recovered from the after effects of the disease. Many of the patients recovered instantaneously without any treatment, whereas many lost their lives. There was a chaos in all the countries across the globe. The patients recovered with the help of proper treatment and were back to their schedule and lifestyle. After, one year from the recovery, few patients started coming up with muscular fatigue, neurological deficits such as tingling in lower limbs, sharp shooting pain travelling throughout the legs. The patient seek treatment for Sciatica or any other nerve suppling the lower limb. The clinical features were misguiding and confused the clinicians. Some diagnosed it as PIVD, few others were confused with compressed and inflamed muscles. The diagnostic tests, including Haematological tests, MRI, CT-Scan, all went in vain.Later, the haematological tests for COVID-19 antibodies and other tests helped in coming up to a conclusion and start with subsequent treatment.This article focuses on the neuropathy and treatment of the same.Copyright © 2022, Anka Publishers. All rights reserved.

A Review of Thyroid Dysfunction due to COVID-19

Coronavirus disease 2019 (COVID-19) affects thyroid function. These changes are due to the direct impact of the virus on thyroid cells via angiotensin-converting­enzyme 2 (ACE2) receptors, inflammatory reaction, apoptosis in thyroid follicular cells, suppression of hypothalamus-pituitary-thyroid axis, an increase in activity of adrenocortical axis, and excess cortisol release due to cytokine storm of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Euthyroid sick syndrome (ESS), thyroiditis, clinical and subclinical hypothyroidism, central hypothyroidism, exacerbation of underlying autoimmune thyroid disease, and clinical and subclinical hyperthyroidism can be associated with coronavirus. Adjuvants in coronavirus vaccines induce autoimmune/inflammatory syndrome known as vaccine adjuvants (ASIA) syndrome. Thyroiditis and Graves' disease have been reported to be associated with ASIA syndrome after some coronavirus vaccinations. Some coronavirus medications, such as hydroxychloroquine, monoclonal antibodies, lopinavir/ritonavir, remdesivir, naproxen, anticoagulants, and glucocorticoids can also affect thyroid tests, and correct diagnosis of thyroid disorders will be more difficult. Conclusion: Changes in thyroid tests may be one of the most important manifestations of COVID-19. These changes can be confusing for clinicians and can lead to inappropriate diagnoses and decisions. Prospective studies should be conducted in the future to increase epidemiological and clinical data and optimize the management of thyroid dysfunctions in patients with COVID-19.

Screening for thyroid disease in pregnancy: a study of Danish clinical practice.

BACKGROUND: Thyroid disease in pregnant women is a matter of clinical awareness, and current clinical guidelines recommend a risk-based screening strategy. This study aimed to evaluate current clinical practice regarding screening for thyroid disease in pregnancy in Denmark. METHODS: A cross-sectional study was performed in the North Denmark Region with consecutive inclusion of 150 pregnant women from Aalborg University Hospital each year in 2020 and 2021. Medical records were reviewed according to the recommended risk-based screening criteria for thyroid disease in pregnancy. Any measurement of thyroid-stimulating hormone (TSH) was assessed 3 months prior to and in pregnancy. RESULTS: Altogether 292 pregnant women who received no current treatment for thyroid disease were included. A total of 81 (27.7%) had a measurement of TSH before or during the pregnancy, and 30 women (10.3%) in the early pregnancy specifically. One or more of the screening criteria for thyroid disease recommended in the Danish clinical practice guideline were fulfilled in 37 of the 81 women (45.7%) with thyroid function tested and among 41 of the 211 (19.4%) women who did not have thyroid function tested before or during pregnancy. CONCLUSION: In a Danish regional investigation, 1 in 4 women had their thyroid function tested in relation to a pregnancy. However, recommended risk-based screening criteria for thyroid disease in pregnancy were heterogeneously distributed. Results encourage considerations on the current practice for the screening of thyroid function in Danish pregnant women and inform the general debate.

Antithyroid Drugs in the Management of Graves' Disease: A Friend and Foe.

Graves' disease is an autoimmune condition in which the patient develops autoantibodies that stimulate the thyroid gland, leading to thyrotoxicosis. We report the case of a 29-year-old female who presented one month postpartum with typical symptoms and signs of thyrotoxicosis. Biochemical and radiological investigations confirmed thyrotoxicosis due to Graves' disease. She received methimazole (MMI) treatment, leading to an allergic reaction in the form of a generalized rash on the body precluding its use. We later started the treatment with propylthiouracil, which she initially tolerated well. During her treatment, she became pregnant and delivered a baby girl by cesarean section at 37 weeks of gestation. The baby developed neonatal thyrotoxicosis due to the transplacental transmission of maternal thyrotropin receptor antibodies. Thyrotoxicosis was short-lived, without consequences, and treated with antithyroid drugs. Three months after delivery, thyroid hormone levels rose considerably, requiring higher doses of propylthiouracil, which resulted in severe hepatic dysfunction, and therefore we stopped the therapy. We admitted her to the hospital for rapid correction of thyroid hormones using steroids, supersaturated potassium iodide, and cholestyramine before she underwent a total thyroidectomy. Our case highlights the challenges the patients and clinicians can face while managing Graves' disease. We discuss the role of a multidisciplinary team approach to care and the options available for treatment in such difficult situations.

The prognostic properties of thyroid disorders, hypothyroidism, and hyperthyroidism in predicting COVID-19 poor outcomes: A systematic review and diagnostic meta-analysis

Purpose: The relationship between thyroid metabolism and coronavirus disease 2019 (COVID-19) inflammation has been extensively investigated. This meta-analysis aimed to evaluate the prognostic properties of unspecified thyroid disorders, hypothyroidism and hyperthyroidism for predicting poor COVID-19 outcomes. Method(s): We conducted systematic literature searching through multiple databases-PubMed, EBSCO and CENTRAL up until 27 September 2021. The main exposure was unspecified thyroid disorders, hypothyroidism or hypothyroidism on-admission status. The outcome of interest was the COVID-19 composite poor outcome that comprises severity, mortality, ICU admission and hospitalisation. Result(s): There were 24517 patients from 20 studies. Meta-analysis showed that thyroid disorder, regardless of its type, was associated with COVID-19 poor outcome (OR 2.92 (95% CI 2.09 - 4.08), P < 0.001;I 2 = 71%, P < 0.001). Unspecified thyroid disorder has a sensitivity of 0.17 (0.08-0.33), specificity of 0.94 (0.88-0.97) and Area Under Curve (AUC) of 0.66. Hypothyroidism has a sensitivity of 0.24 (0.12-0.42), specificity of 0.92 (0.87-0.96) and AUC of 0.77. Hyperthyroidism has a sensitivity of 0.05 (0.02-0.11), specificity of 0.98 (0.88-1.00) and AUC of 0.36. In this pooled analysis, the posttest probability of unspecified thyroid disease, hypothyroidism and hyperthyroidism were 42%, 27% and 8% for poor outcomes, respectively. Conclusion(s): Thyroid disorders are associated with poor COVID-19 prognosis.Copyright © 2022 Authors. All rights reserved.

Thyrotoxicosis in patients with a history of Graves' disease after SARS-CoV-2 vaccination (adenovirus vector vaccine): Two case reports.

BACKGROUND: Vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which were approved for emergency use have been administered on a large scale globally to contain the pandemic coronavirus disease 2019 (COVID-19) and to save lives. Vaccine safety is one of the issues under surveillance and a possible correlation between vaccines and thyroid function has been reported. However, reports of the impact of coronavirus vaccines on those with Graves' disease (GD) are rare. CASE SUMMARY: This paper presents two patients with underlying GD in remission, both developed thyrotoxicosis and one developed thyroid storm following the adenovirus-vectored vaccine (Oxford-AstraZeneca, United Kingdom). The objective of this article is to raise awareness regarding a possible association between COVID-19 vaccination and the onset of thyroid dysfunction in patients with underlying GD in remission. CONCLUSION: Receiving either the mRNA or an adenovirus-vectored vaccine for SARS-CoV-2 could be safe under effective treatment. Vaccine induced thyroid dysfunction has been reported, but the pathophysiology still not well understood. Further investigation is required to evaluate the possible predisposing factors for developing thyrotoxicosis especially in patients with underlying GD. However, early awareness of thyroid dysfunction following vaccination could avoid a life-threatening event.

A patient with advanced breast cancer and hyperthyroidism associated with struma ovarii.

Not required for Clical Vignettes.

COVID-19 and thyroid function: What do we know so far?

Coronavirus disease 2019 (COVID-19) was characterized as a pandemic in March, 2020 by the World Health Organization. COVID-19 is a respiratory syndrome that can progress to acute respiratory distress syndrome, multiorgan dysfunction, and eventually death. Despite being considered a respiratory disease, it is known that other organs and systems can be affected in COVID-19, including the thyroid gland. Thyroid gland, as well as hypothalamus and pituitary, which regulate the functioning of most endocrine glands, express angiotensin-converting enzyme 2 (ACE2), the main protein that functions as a receptor to which SARS-CoV-2 binds to enter host cells. In addition, thyroid gland is extremely sensitive to changes in body homeostasis and metabolism. Immune system cells are targets for thyroid hormones and T3 and T4 modulate specific immune responses, including cell-mediated immunity, natural killer cell activity, the antiviral action of interferon (IFN) and proliferation of T- and B-lymphocytes. However, studies show that patients with controlled hypothyroidism and hyperthyroidism do not have a higher prevalence of COVID-19, nor do they have a worse prognosis when infected with the virus. On the other hand, retrospective observational studies, prospective studies, and case reports published in the last two years reported abnormal thyroid function related to acute SARS-CoV-2 infection or even several weeks after its resolution. Indeed, a variety of thyroid disorders have been documented in COVID-19 patients, including non-thyroidal illness syndrome (NTIS), subacute thyroiditis and thyrotoxicosis. In addition, thyroid disease has already been reported as a consequence of the administration of vaccines against SARS-CoV-2. Overall, the data revealed that abnormal thyroid function may occur during and in the convalescence post-COVID condition phase. Although the cellular and molecular mechanisms are not completely understood, the evidence suggests that the "cytokine storm" is an important mediator in this context. Thus, future studies are needed to better investigate the pathophysiology of thyroid dysfunction induced by COVID-19 at both molecular and clinical levels.

Increased incidence of Graves' disease during the SARS-CoV2 pandemic.

INTRODUCTION: COVID-19 has a wide spectrum of clinical severity and there is evidence that SARS-Cov2 affects several organs and systems. Among the organs affected since the beginning of the pandemic, the relationship between SARS-CoV-2 infection and thyroid involvement has been demonstrated. Novel and highly effective messenger RNA and DNA-based vaccines have been rapidly developed to decrease SARS-CoV-2 morbidity and mortality. Early after mass vaccinations, cases of thyroid dysfunction mainly including episodes of subacute thyroiditis, began to be reported like adverse effects. The objective of this study is to determine the impact of the pandemic, both due to SARS-CoV2 infections and vaccinations, on the incidence of Graves' disease (GD). METHODS: Cross-sectional, observational study comparing incidence of GD in adult population (over 18 years) before (2017-2019) and after (2020-2021) Covid-19 pandemic. Only patients with new cases of GD, no relapsed diseases, were included. SARS-CoV-2 diagnosis was based on nucleic acid amplification tests on nasopharyngeal swabs or measurement of class M and class G antibodies to SARS-CoV-2 by highly specific assays. Data on incidence and vaccination related to SARS-CoV-2 infection were obtained from the public records from Castilla y León autonomous regional government. RESULTS: A total of 180 subjects were diagnosed and treated for GD during the study period. We observed a notable increase in expected GD cases in 2021 compared to 2017-19. The number of GD cases was higher in the second (Q2) quarter. Among 2021 GD cases, 42/66 patients (63.6%) had been vaccinated in the 90 days before symptom onset, but none of them in the first quarter of the year. A total of 97.7% were women with a mean age of 48.9 (SD 15.6) years. On average they were diagnosed 19.9 (SD 17.6) days after receiving the vaccine. A total of 7/42 (16.67%) had another previously diagnosed autoimmune disease and 11/42 (26.19%) were smokers. DISCUSSION: Our results show a notable increase in the incidence of GD during the year 2021, specially in women with a history of smoking. Hyper activation of the immune system induced by SARS-CoV2 and by the recently released SARS-COV-2 vaccines has been highlighted in recent months. To assess whether this observed increase in the incidence of GD is sustained in the coming years or has simply been a precipitous trigger for individuals who were already predisposed to develop the disease, future studies will be needed.

The Influence of SARS-CoV-2 Infection on the Thyroid Gland.

It is important to acknowledge the impact that COVID-19 has on the thyroid gland and how the thyroid gland status before and during infection affects SARS-CoV-2 severity. To this day those dependencies are not fully understood. It is known that the virus uses angiotensin-converting enzyme-2 as the receptor for cellular entry and it can lead to multiple organ failures due to a cytokine storm. Levels of proinflammatory molecules (such as cytokines and chemokines) which are commonly elevated during infection were significantly higher in observed SARS-CoV-2-positive patients. In terms of hypothyroidism, hyperthyroidism, and autoimmune thyroid diseases, there is no proof that those dysfunctions have a direct impact on the more severe courses of COVID-19. Regarding hyper- and hypothyroidism there was no consequential dependency between the frequency of SARS-CoV-2 infection morbidity and more severe post-infectious complications. When it comes to autoimmune thyroid diseases, more evaluation has to be performed due to the unclear relation with the level of antibodies commonly checked in those illnesses and its binding with the mentioned before virus. Nonetheless, based on analyzed works we found that COVID-19 can trigger the immune system and cause its hyperactivity, sometimes leading to the new onset of autoimmune disorders. We also noticed more acute SARS-CoV-2 courses in patients with mainly reduced free triiodothyronine serum levels, which in the future, might be used as a mortality indicating factor regarding SARS-CoV-2-positive patients. Considering subacute thyroiditis (SAT), no statistically important data proving its direct correlation with COVID-19 infection has been found. Nevertheless, taking into account the fact that SAT is triggered by respiratory tract viral infections, it might be that SARS-CoV-2 can cause it too. There are many heterogenous figures in the symptoms, annual morbidity distribution, and frequency of new cases, so this topic requires further evaluation.

Thyroid storm in a pregnant woman with COVID-19 infection: A case report and review of literatures.

BACKGROUND: The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been found to be responsible for the recent global pandemic known as coronavirus disease 2019 (COVID-19). SARS-CoV-2 infections not only result in significant respiratory symptoms but also cause several extrapulmonary manifestations, such as thrombotic complications, myocardial dysfunction and arrhythmia, thyroid dysfunction, acute kidney injury, gastrointestinal symptoms, neurological symptoms, ocular symptoms, and dermatological complications. We present the first documented case of thyroid storm in a pregnant woman precipitated by SARS-CoV-2. CASE SUMMARY: A 42-year-old multiparous woman at 35 + 2 wk of gestation visited the emergency room (ER) with altered mentation, seizures, tachycardia, and high fever. The patient showed no remarkable events in the prenatal examination, and the nasopharyngeal COVID-19 polymerase chain reaction (PCR) test was positive two days before the ER visit. The results of laboratory tests, such as liver function test, serum electrolytes, blood glucose, blood urea nitrogen, and creatinine, were all within the normal ranges. However, the thyroid function test showed hyperthyroidism, and the nasopharyngeal COVID-19 PCR test was positive, as expected. No specific findings were observed on the brain computed tomography, and there were no signs of lateralization on neurological examination. Fetal heartbeat and movement were good, and there were no significant uterine contractions. The initial impression was atypical eclampsia. However, the patient's condition worsened, and a cesarean section was performed under general anesthesia; a healthy boy was delivered, and 12 h after delivery, the patient's seizures disappeared and consciousness was restored. The patient was referred to an endocrinologist for hyperthyroidism, and a thyroid storm with Graves' disease was diagnosed. Here, SARS-CoV-2 was believed to be the trigger for the thyroid storm, considering that the patient tested positive for COVID-19 two days before the seizures. CONCLUSION: In pregnant women presenting with seizures or changes in consciousness, the possibility of a thyroid storm should be considered. There are various causes for a thyroid storm, but given the recent pandemic, it is necessary to bear in mind that the thyroid storm may be precipitated by COVID-19.

Clinical characteristics and risk factors for mortality in patients with COVID-19: A retrospective nationwide study in Malaysia

Background: Age and multiple comorbidities have been reported to influence the case fatality rate of COVID-19 worldwide, so also in Malaysia;however, to date, no scientific study among the local population has been published to confirm this. This study aimed to determine the overall demographics and clinical characteristics of COVID-19 non-survivors in Malaysia, stratified by age (< 65 vs. >= 65 years old). The mortality was also compared between two half-year periods: March-August 2020 and September 2020-March 2021. Method(s): Daily reports containing demographics and medical history of COVID-19 non-survivors from March 2020 to March 2021 were obtained from the Malaysian Ministry of Health website. All information was extracted retrospectively and analysed using descriptive and inferential statistics with SPSS. Result(s): Of 1192 COVID-19 non-survivors, the overall mean (SD) age was 64.8 (15.7) years, with 64.7% male. Death was seen mostly among 50- to 64-year-olds (33.1%) and 65- to 74-year-olds (24.8%). The presence of underlying hypertension (61.8%) and diabetes mellitus (48.2%) were the most common comorbid diseases encountered in the COVID-19 non-survivors. Underlying hypertension, stroke, heart disease and dyslipidaemia were significantly higher among COVID-19 non-survivors who were >= 65 years old compared to those < 65 (p < 0.05). Mortality was a lot higher in September 2020-March 2021 compared to March 2020-August 2020 (91.3% vs. 8.3%). Conclusion(s): Older age, male gender and the presence of multimorbidity (hypertension, diabetes mellitus, stroke and heart disease) are risk factors that contribute to mortality due to COVID-19 in Malaysia, especially among those >= 65 years old. Copyright © The Author(s) 2022.

Impact of the COVID-19 pandemic on the incidence, seasonal distribution, and characteristics of subacute thyroiditis.

PURPOSE: An increasing number of cases of subacute thyroiditis (SAT) related to the coronavirus disease 2019 (COVID-19) and its vaccines continue to be published. The aim of this study was to investigate any change in the incidence and characteristics of SAT by comparing the pre-pandemic and pandemic periods. METHODS: This retrospective, single-center study included 432 newly-diagnosed SAT patients between January 2018 and December 2021. The annual frequency of SAT was calculated as the number of newly-diagnosed SAT cases divided by the total number of outpatients that year. RESULTS: The frequencies of newly-diagnosed SAT were 0.136% in 2018, 0.127% in 2019, 0.157% in 2020, and 0.114% in 2021 (p = 0.19). While SAT patients were clustered in the autumn (35.1%) in 2018 and 2019, it was found that this cluster shifted to the winter (33.0%) in 2020 and 2021, in parallel with COVID-19 case peaks (p = 0.017). The patients were separated into two groups as pre-COVID-19 pandemic SAT (n = 272) and COVID-19 pandemic SAT (n = 160). The mean ages of the groups were similar. There were more male patients in the COVID-19 pandemic SAT group than in the pre-pandemic group (30.6% vs. 18.7%, p = 0.005). Frequencies of overt hyperthyroidism and median free-thyroxine levels were significantly higher in the COVID-19 pandemic SAT group (p = 0.029, p = 0.001). Treatment modalities, recurrence rates, and permanent hypothyroidism were similar in both groups. CONCLUSION: With the COVID-19 pandemic, although there was a change in seasonal variation of SAT and an increase in the number of male patients, there was no change in the incidence and clinical course of SAT.

Increased Incidence and Severity of New Graves Disease Diagnoses in Youth During the COVID-19 Pandemic.

OBJECTIVE: Graves disease (GD), an autoimmune disease of the thyroid, is likely caused by a combination of genetic predisposition and environmental triggers. Recent data suggest that COVID-19 may be associated with the development of autoimmune disease. The aim of this study was to assess the incidence and characteristics of new GD diagnoses in youth prior to and during the COVID-19 pandemic. METHODS: We performed a retrospective chart review of all new GD diagnoses in patients aged 0 to 18 years diagnosed at a tertiary care pediatric hospital between January 1, 2018, and December 31, 2021. RESULTS: Over a 4-year period, 51 patients had been diagnosed with new-onset GD. We observed an increased incidence in new-onset GD during the pandemic compared with that in the 2 prior years (P = .01). During the pandemic period, heart rates (P = .03) as well as systolic (P = .005) and diastolic (P = .01) blood pressures were higher at initial evaluation, patients more frequently reported palpitations (P = .03) and tremors (P = .04), and an increased proportion of patients required beta-blockade treatment at diagnosis (P = .002). The percentage of patients requiring thionamide treatment and thionamide doses had been similar over time. CONCLUSION: We identified an increase in new-onset pediatric GD diagnoses during the COVID-19 pandemic. In addition, youths had increased severity of symptoms and more frequently required beta-blockade treatment at diagnosis. Further study of the relationship between COVID-19 and autoimmune thyroid disease is needed.

A case of aseptic bilateral cavernous sinus thrombosis following a recent inactivated SARS-CoV-2 vaccination.

This case report aims to describe the first report of bilateral aseptic cavernous sinus thrombosis (CST) with a recent history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. A 50-year-old woman presented with bilateral proptosis, decreased vision, and ophthalmoplegia 16 days following CoronaVac® vaccine. The visual acuity of the left eye was 20/150, while the right eye was no light perception with a hyperemic optic nerve head. She had a history of hyperthyroidism and currently on warfarin consumption. Laboratory results depicted elevated free T4, free T3, international normalized ratio, and low protein S and C. Magnetic resonance imaging showed bilateral CST, and high-dose methylprednisolone along with fondaparinux was given. The symptoms were significantly resolved, with the visual acuity of the left eye being improved to 20/20 but not the right eye. Bilateral CST has not been previously reported following inactivated SARS-CoV-2 vaccination. The underlying systemic conditions should be taken into consideration for the possibility of the inactivated SARS-CoV-2 vaccine-related event.