key: cord-0781956-mmrrtkyc
authors: Ramsay, Nicolas; Carizey, Rene; Popa, Daniel
title: Coronavirus Disease 2019 Induced Thyroiditis
date: 2021-01-15
journal: J Emerg Med
DOI: 10.1016/j.jemermed.2021.01.012
sha: 8baeb89f7c76579a652f7be183394fd9c1b7ed19
doc_id: 781956
cord_uid: mmrrtkyc

Background Coronavirus Disease 2019 (COVID-19) is a disease that presents with acute respiratory symptoms that are well documented and sequelae that are yet to be fully understood. Case Report We present the case of a 51-year old female, recently diagnosed with COVID-19, who presented with symptoms including chest pain, palpitations, difficulty swallowing, and anterior neck discomfort. We ultimately diagnosed her with COVID-19 induced thyroiditis and discharged her on propranolol and non-steroidal anti-inflammatory medication. Why should an emergency physician be aware of this? Thyroiditis can present with similar symptoms to other etiologies like pulmonary embolism. We discuss the process of evaluating and treating thyroiditis. We further discuss the risk of administering iodinated contrast media which could further exacerbate thyroid dysfunction.

Coronavirus Disease 2019 (COVID-19) is a respiratory disease caused by severe acute 18 respiratory syndrome coronavirus 2 (SARS-CoV-2) first identified in Wuhan, China in late 2019 19 (1) . It can present with mild symptoms like fever, cough, loss of taste and smell, or more severe 20 symptoms including dyspnea and acute respiratory distress syndrome (ARDS). Although 21 presenting symptoms are well documented, clinicians continue to uncover sequelae. In addition 22

to respiratory disease, some complications include hypercoagulability with venous 23 thromboembolism (2), neurologic disease including stroke (3), and liver disease which can 24 include hepatic failure, cirrhosis, and encephalopathy (4). 25

Thyroiditis is an inflammatory condition leading to hyperthyroidism with acute 26 inflammation of the gland causing neck pain, tremors, palpitations, dyspnea, insomnia, and 27 anxiety. Unfortunately, these symptoms have a wide differential diagnosis among emergency 28 department patients which includes pulmonary embolism, dysrhythmia, myocardial ischemia, 29 electrolyte derangements, and acute infection. Known causes of thyroiditis include autoimmune 30 dysfunction, medications such as amiodarone or lithium, and viral infection. As cases of SARS-31

CoV-2 continue to rise, recognizing COVID-19 as a cause of thyroiditis can help guide 32 emergency department work-up and management of these patients. intermittent chills, occasional tremor, and intermittent fevers. Additionally, she endorsed 41 difficulty performing simple tasks at home such as chopping vegetables for approximately five 42 minutes before having to sit down for approximately 20 minutes to catch her breath. She 43 continued to have a cough with some productive sputum. She further reported difficulty 44 swallowing, stating that she felt something was twisted around at the back of her throat and in 45 her neck, particularly at the left anterior aspect. 46

Her initial vital signs revealed an afebrile temperature of 36.8 degrees Celsius, a 47 tachycardic heart rate of 117 bpm, mild tachypnea with a respiratory rate of 20 breaths per 48 minute, a slightly elevated blood pressure of 149/84 mmHg, and a normal oxygen saturation of 49 97%. Physical examination revealed a distressed and ill woman appearing her stated age. She 50 appeared mildly dehydrated with dry mucous membranes and mild posterior pharyngeal 51 erythema. Her cardiac examination was tachycardic but otherwise normal. Her respiratory 52 examination revealed tachypnea, mild respiratory distress, and mild increased work of breathing 53 with otherwise normal breath sounds. Her abdominal examination was normal as were her skin, 54 neurological, and psychiatric examinations. Her anterior neck was severely tender to palpation, 55 worst on the left anterior aspect, with no thyroid enlargement noted. No skin changes overlay the 56 anterior neck. 57

Given the continued and, in fact, worsening symptoms after her recent COVID-19 58 diagnosis, our concerns for worsening COVID-19 pneumonia, thyroiditis, and pulmonary 59 embolism (PE), a known complication of COVID-19, were significant and shaped the initial 60 work-up. A cardiac etiology such as viral myocarditis and acute coronary syndrome were also 61 included in our differential diagnosis. Given our high suspicion for PE, we ordered a computed 62 comprehensive metabolic panel, complete blood count, venous blood gas with lactate, and 64

troponin. An ECG had already been obtained in the triage area which showed sinus tachycardia 65 at a rate of 106 bpm without signs of ischemia. Since she would be going to the CT scanner and 66 receiving a contrast study already, we reasoned that obtaining a CT soft tissue neck with contrast 67 would be a good test to evaluate her neck pain and dysphagia which was concerning for 68 thyroiditis or a deeper space infection such as a retropharyngeal abscess or lymphadenitis, 69 although neither was a condition associated with COVID-19 to our knowledge. 70

The initial laboratory results were remarkable for a minimal leukocytosis of 10.95 k/uL 71 (5-10 k/uL) with a normal differential and a new, mild anemia with a hemoglobin of 9.9 g/dL 72 (12-15.5 g/dL) which was down from 12.3g/dL 2.5 months prior. She denied any hematemesis, 73 hematochezia, melena, or heavy menstrual periods. Her CT angiogram of the chest was negative 74 for PE and otherwise normal. There were none of the typical COVID-19 findings. 75

Her CT soft tissue neck, however, was revealing and concerning for thyroiditis ( Figure  76 1). The radiologist report found "slightly heterogeneous attenuation/enhancement of the thyroid 77 gland with mild perithyroidal edema." In addition, there were a "few mildly enlarged right 78 supraclavicular lymph nodes, [the] largest measuring about 1.5 x 2 cm." These enlarged lymph 79 nodes, however, were on the contralateral side of the neck from where the patient reported pain, 80

implying that the etiology of her pain was not due to lymphadenitis. Given the lack of other 81 etiology, we felt that her left sided throat pain was likely secondary to thyroiditis. Given the CT 82 finding, we ordered a thyroid stimulating hormone (TSH) level which resulted low at 0.00004 83 mU/mL (0.4-4.0 mU/mL) and a free thyroxine level which resulted high at 1.90 ng/dL (0.8-1.8 84 ng/dL), although not as high as we expected given her clinical picture. However, in conjunction recommended propranolol and non-steroidal anti-inflammatory (NSAID) medication such as 87 ibuprofen for her pain and for the anti-inflammatory benefit. They did not recommend any 88 corticosteroid treatment. They additionally requested a thyroid stimulating immunoglobulin to 89 evaluate for Grave's disease and none was detected. Additionally, the endocrinologist on call 90 recommended close return precautions given that she had received an iodinated contrast bolus 91 for her CT scans. We prescribed propranolol 20mg twice daily for two weeks and recommended 92 close outpatient follow up with an endocrinologist. 93

Subsequent to her ED visit, she had no worsening of her symptoms. Seventeen days after 94 her ED visit, repeat laboratory testing showed immeasurably low TSH, a normal free thyroxine 95 (T4) level of 1.50 ng/dL, and an elevated total triiodothyronine (T3) level of 203 ng/dL (75-195 96 ng/dL). Her endocrinologist planned to repeat thyroid function testing but did not prescribe any 97 further propranolol or other medication. 98

As COVID-19 continues to spread, emergency physicians should consider viral 100 thyroiditis in the differential diagnosis of patients presenting to the emergency department with 101 In an emergency department setting, thyrotoxicosis, the clinical syndrome secondary to 126 increased thyroid hormones regardless of etiology, is diagnosed using the patient's clinical 127 presentation as well as a low TSH level. Therefore, if the emergency physician suspects 128 thyrotoxicosis, the initial workup should include basic laboratory testing as well as serum TSH 129 levels with subsequent free T4 if the TSH level is abnormal. Laboratory values guide 130 management (11)( Table 1) . Typically, thyrotoxicosis requires additional outpatient workup once 131 testing incorporates a combination of serum testing for TSH and T3/T4 levels, thyroid 133 antibodies, thyroid duplex ultrasound studies, and a radioactive iodine uptake (RAIU) scan to 134 help delineate the underlying cause of the thyrotoxicosis. 135

Furthermore, emergency physicians should note the risk of further exacerbating the 136 thyrotoxicosis by using iodinated contrast as part of the imaging modality of choice. The normal 137 acute response to excess iodine by the thyroid gland, known as the Wolff-Chaikov effect, was 138 first described in 1948 when rats exposed to high iodine levels transiently decreased thyroid 139 hormone synthesis (12). If this effect is impaired, iodine induced hyperthyroidism, known as the 

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