Graves’ Thyrotoxicosis following SARS-CoV-2 Infection

Harris, Asaf; Al Mushref, Mazen

OBJECTIVE: Graves’ disease (GD) is an autoimmune thyroid disease thought to develop following environmental exposure in patients with genetic predisposition. Our objective is to present the first report of GD onset immediately following recovery from mild coronavirus disease 2019 (COVID-19), a close temporal occurrence which should be studied further. METHODS: We describe the clinical course and laboratory features, including thyroid function studies, antibody testing, and PCR testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). RESULTS: A 21-year-old woman with pre-diabetes, obesity, asthma, and GERD presented to the emergency department (ED) reporting three days of tachycardia, palpitations, anxiety, and shortness of breath.. Laboratory investigation revealed a TSH level of 0.01 mcIU/mL (0.30-5.00 mcIU/mL) with free T4 3.8 ng/dL (0.6-1.6 ng/dL),prompting Endocrinology consultation. On physical exam she had mild diffuse thyromegaly without tenderness, and history included hypothyroidism in her mother. Antibody testing results demonstrated thyroid stimulating immunoglobulin 2.6 (< 1.3 TSI index) and thyrotropin receptor antibody 17 IU/L (0.00-1.75 IU/L). Sixteen days before presenting to ED she was diagnosed with COVID-19 by PCR test after reporting typical symptoms including fever. Infectious symptoms resolved within ten days. She achieved clinical and laboratory improvement with a combination of methimazole and beta blocker therapy. CONCLUSION: This case documents the occurrence of Graves’ thyrotoxicosis following mild symptomatic COVID-19. Whether the preceding infection is coincidental or contributed to GD development requires definitive studies. This presentation may align with the theory of a viral link in the development of autoimmune thyroid disease in those with genetic predisposition.