Persistent pain: Recurrent severe subacute thyroiditis from covid 19 infection

ABSTRACT

Subacute thyroiditis is an acute inflammatory response in the thyroid which usually follows a viral infection. This report highlights a case of subacute thyroiditis in a patient with a history of benign COVID 19 infection without indication for supplemental oxygen or hospitalization. This case is unique in the fact that the patient required multiple doses of steroids for symptom control. A 36-year-old female with a past medical history of hyperlipidemia, essential hypertension, obesity, type two diabetes, and recent COVID-19 infection six months prior presented to the hospital for evaluation of persistent anterior neck pain, fevers up to 100.9- F, ten pound weight loss, and palpitations. Two months before presentation she developed anterior neck pain that radiated into the left side of her neck and jaw. This was evaluated by an outpatient otolaryngologist who performed a nasopharyngeal laryngoscopy with unremarkable findings. She was placed on a muscle relaxant, ibuprofen, and a course of steroids. She saw another physician who trialed an additional course of steroids shortly after. Unfortunately she continued to experience excruciating discomfort prompting this hospitalization. Admission labs revealed that the patient's TSH was less than 0.01 uIU/mL. Her free T4 was 1.9 ng/dL and her free T3 was 3.6 pg/mL. A CT scan of the neck showed a 1.9 x 1.0 cm hypodense lesion. Further imaging with a thyroid ultrasound showed a heterogenous thyroid with generalized hypo echogenicity, decreased blood flow, without discrete nodules, cysts, or calcifications concerning for acute thyroiditis. The patient was started on intravenous methylprednisolone with improvement in symptoms. She was subsequently transitioned to oral prednisone on discharge. Subacute thyroiditis most commonly follows a viral infection. With our patient, symptoms developed shortly after her COVID19 infection. Once a diagnosis of subacute thyroiditis is made, patients are treated with a short course of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and occasionally oral steroids which resolves most symptoms. This case was unique in that our patient required three regimens of steroids before her symptoms improved. Given these findings, a prolonged course of steroids may be indicated for covid-19 induced subacute thyroiditis.