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Covid and hyperthyroidism

2022-08-02T17:25:23Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

Covid and hypothyroidism

2022-08-02T17:24:58Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

Covid and thyroid disease

2022-08-02T17:24:15Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID and euthyroid sick syndrome

2022-08-02T17:21:55Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID and hyperthyroidism

2022-08-02T17:21:31Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID and hypothyroidism

2022-08-02T17:21:14Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19 and Hashimoto thyroiditis

2022-08-02T17:20:57Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19 and Grave's disease

2022-08-02T17:20:21Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19 and Hyperthyroidism

2022-08-02T17:19:52Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19 and hypothyroidism

2022-08-02T17:19:31Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

Post-covid-19 thyroid storm

2022-08-02T17:18:52Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

Post-COVID-19 Euthyroid sick syndrome

2022-08-02T17:18:25Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

Post-COVID-19 Hashimoto thyroiditis

2022-08-02T17:17:53Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

Post-covid-19 Grave's disease

2022-08-02T17:17:18Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

Post-COVID-19 hyperthyroidism

2022-08-02T17:16:55Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

Post-covid-19 hypothyroidism

2022-08-02T17:16:36Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

Post-COVID-19 thyroid diseases

2022-08-02T17:16:18Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

Post-COVID-19 thyroid disease

2022-08-02T17:15:50Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

Post-COVID thyroid diseases

2022-08-02T17:15:21Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19-associated Grave's diseases

2022-08-02T17:14:57Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19-associated Graves disease

2022-08-02T17:14:20Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19-associated hyperthyroidism

2022-08-02T17:13:50Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19-associated hypothyroidism

2022-08-02T17:13:15Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19 euthyroid sick syndrome

2022-08-02T17:12:44Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19 Hashimoto thyroiditis

2022-08-02T17:12:17Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19 hypothyroidism

2022-08-02T17:11:52Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19 hyperthyroidism

2022-08-02T17:11:31Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19 graves disease

2022-08-02T17:11:11Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19 thyroid disease

2022-08-02T17:10:48Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID thyroid disease

2022-08-02T17:10:17Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-associated thyroid diseases

2022-08-02T17:09:49Z

Mitra Chitsazan: Redirected page to COVID-19-associated thyroid diseases

#REDIRECT [[COVID-19-associated thyroid diseases]]

COVID-19-associated thyroid diseases

2022-08-02T17:06:21Z

Mitra Chitsazan:

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}} {{Mitra}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*[[Prognosis]] has generally been good in most cases of [[COVID-19]] patients with [[hyperthyroidism]]/[[hypothyroidism]].
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., euthyroid sick syndrome) was associated with higher mortality and increased [[IL-6]], suggesting poor [[prognosis]] in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of serum [[thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total [[T4]] and [[T3]] measurements are influenced by multiple conditions affecting serum [[thyroxine-binding globulin]] ([[TBG]]). Thus, the measurement of free thyroid hormones; [[free T4]] ([[FT4]]) and [[free T3]] ([[fT3]]), is the gold standard for the diagnosis of [[Graves' disease]].<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the [[TSH]] receptor ([[TRAbs]]) are pathognomonic for [[Graves' disease]]. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state <ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with [[Hashimoto's thyroiditis]]:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-[[TPO]]) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis <ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild [[euthyroid sick syndrome]]
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate [[euthyroid sick syndrome]]
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe [[euthyroid sick syndrome]]
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr [[radioactive iodine uptake]] ([[RAIU]]) is a diagnostic measure for [[Graves' disease]], which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[RAIU]] is generally increased in [[Graves' disease]] because of the action of stimulating [[TRAbs]].
* Normal values for [[RAIU]] 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Ultrasound}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | [[Ophthalmopathy]], [[dermopathy]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory markers
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of [[hypothyroidism]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-08-02T17:06:07Z

Mitra Chitsazan:

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}} {{MC}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*[[Prognosis]] has generally been good in most cases of [[COVID-19]] patients with [[hyperthyroidism]]/[[hypothyroidism]].
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., euthyroid sick syndrome) was associated with higher mortality and increased [[IL-6]], suggesting poor [[prognosis]] in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of serum [[thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total [[T4]] and [[T3]] measurements are influenced by multiple conditions affecting serum [[thyroxine-binding globulin]] ([[TBG]]). Thus, the measurement of free thyroid hormones; [[free T4]] ([[FT4]]) and [[free T3]] ([[fT3]]), is the gold standard for the diagnosis of [[Graves' disease]].<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the [[TSH]] receptor ([[TRAbs]]) are pathognomonic for [[Graves' disease]]. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state <ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with [[Hashimoto's thyroiditis]]:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-[[TPO]]) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis <ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild [[euthyroid sick syndrome]]
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate [[euthyroid sick syndrome]]
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe [[euthyroid sick syndrome]]
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr [[radioactive iodine uptake]] ([[RAIU]]) is a diagnostic measure for [[Graves' disease]], which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[RAIU]] is generally increased in [[Graves' disease]] because of the action of stimulating [[TRAbs]].
* Normal values for [[RAIU]] 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Ultrasound}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | [[Ophthalmopathy]], [[dermopathy]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory markers
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of [[hypothyroidism]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-08-02T17:05:03Z

Mitra Chitsazan: /* Radioactive iodine uptake */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*[[Prognosis]] has generally been good in most cases of [[COVID-19]] patients with [[hyperthyroidism]]/[[hypothyroidism]].
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., euthyroid sick syndrome) was associated with higher mortality and increased [[IL-6]], suggesting poor [[prognosis]] in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of serum [[thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total [[T4]] and [[T3]] measurements are influenced by multiple conditions affecting serum [[thyroxine-binding globulin]] ([[TBG]]). Thus, the measurement of free thyroid hormones; [[free T4]] ([[FT4]]) and [[free T3]] ([[fT3]]), is the gold standard for the diagnosis of [[Graves' disease]].<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the [[TSH]] receptor ([[TRAbs]]) are pathognomonic for [[Graves' disease]]. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state <ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with [[Hashimoto's thyroiditis]]:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-[[TPO]]) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis <ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild [[euthyroid sick syndrome]]
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate [[euthyroid sick syndrome]]
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe [[euthyroid sick syndrome]]
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr [[radioactive iodine uptake]] ([[RAIU]]) is a diagnostic measure for [[Graves' disease]], which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[RAIU]] is generally increased in [[Graves' disease]] because of the action of stimulating [[TRAbs]].
* Normal values for [[RAIU]] 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Ultrasound}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | [[Ophthalmopathy]], [[dermopathy]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory markers
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of [[hypothyroidism]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-08-02T17:04:47Z

Mitra Chitsazan: /* Radioactive iodine uptake */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*[[Prognosis]] has generally been good in most cases of [[COVID-19]] patients with [[hyperthyroidism]]/[[hypothyroidism]].
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., euthyroid sick syndrome) was associated with higher mortality and increased [[IL-6]], suggesting poor [[prognosis]] in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of serum [[thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total [[T4]] and [[T3]] measurements are influenced by multiple conditions affecting serum [[thyroxine-binding globulin]] ([[TBG]]). Thus, the measurement of free thyroid hormones; [[free T4]] ([[FT4]]) and [[free T3]] ([[fT3]]), is the gold standard for the diagnosis of [[Graves' disease]].<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the [[TSH]] receptor ([[TRAbs]]) are pathognomonic for [[Graves' disease]]. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state <ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with [[Hashimoto's thyroiditis]]:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-[[TPO]]) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis <ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild [[euthyroid sick syndrome]]
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate [[euthyroid sick syndrome]]
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe [[euthyroid sick syndrome]]
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr [[radioactive iodine uptake]] ([[RAIU]]) is a diagnostic measure for [[Graves' disease]], which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[RAIU]] is generally increased in [[Graves' disease]] because of the action of stimulating [[TRAbs]].
* Normal values for [[RAIU]] 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|[[Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Ultrasound}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | [[Ophthalmopathy]], [[dermopathy]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory markers
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of [[hypothyroidism]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-08-02T17:03:15Z

Mitra Chitsazan: /* Radioactive iodine uptake */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*[[Prognosis]] has generally been good in most cases of [[COVID-19]] patients with [[hyperthyroidism]]/[[hypothyroidism]].
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., euthyroid sick syndrome) was associated with higher mortality and increased [[IL-6]], suggesting poor [[prognosis]] in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of serum [[thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total [[T4]] and [[T3]] measurements are influenced by multiple conditions affecting serum [[thyroxine-binding globulin]] ([[TBG]]). Thus, the measurement of free thyroid hormones; [[free T4]] ([[FT4]]) and [[free T3]] ([[fT3]]), is the gold standard for the diagnosis of [[Graves' disease]].<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the [[TSH]] receptor ([[TRAbs]]) are pathognomonic for [[Graves' disease]]. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state <ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with [[Hashimoto's thyroiditis]]:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-[[TPO]]) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis <ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild [[euthyroid sick syndrome]]
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate [[euthyroid sick syndrome]]
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe [[euthyroid sick syndrome]]
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr [[radioactive iodine uptake]] ([[RAIU]]) is a diagnostic measure for [[Graves' disease]], which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[RAIU]] is generally increased in [[Graves' disease]] because of the action of stimulating [[TRAbs]].
* Normal values for [[RAIU]] 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|[[Thyroid Disease]]}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|[[TSH]] receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid [[Ultrasound]]}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|[[Color flow Doppler]]}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|[[Radioactive iodine uptake]]/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|[[Graves' disease]]}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | [[Ophthalmopathy]], [[dermopathy]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory markers
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of [[hypothyroidism]]
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-08-02T17:00:31Z

Mitra Chitsazan: /* Laboratory Findings */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*[[Prognosis]] has generally been good in most cases of [[COVID-19]] patients with [[hyperthyroidism]]/[[hypothyroidism]].
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., euthyroid sick syndrome) was associated with higher mortality and increased [[IL-6]], suggesting poor [[prognosis]] in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of serum [[thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total [[T4]] and [[T3]] measurements are influenced by multiple conditions affecting serum [[thyroxine-binding globulin]] ([[TBG]]). Thus, the measurement of free thyroid hormones; [[free T4]] ([[FT4]]) and [[free T3]] ([[fT3]]), is the gold standard for the diagnosis of [[Graves' disease]].<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the [[TSH]] receptor ([[TRAbs]]) are pathognomonic for [[Graves' disease]]. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state <ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with [[Hashimoto's thyroiditis]]:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-[[TPO]]) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis <ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild [[euthyroid sick syndrome]]
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate [[euthyroid sick syndrome]]
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe [[euthyroid sick syndrome]]
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T20:14:58Z

Mitra Chitsazan: /* Differentiating COVID-19-associated thyroid diseases from other Diseases */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*[[Prognosis]] has generally been good in most cases of [[COVID-19]] patients with [[hyperthyroidism]]/[[hypothyroidism]].
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., euthyroid sick syndrome) was associated with higher mortality and increased [[IL-6]], suggesting poor [[prognosis]] in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T20:14:37Z

Mitra Chitsazan: /* Differentiating COVID-19-associated thyroid diseases from other Diseases */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*[[Prognosis]] has generally been good in most cases of [[COVID-19]] patients with [[hyperthyroidism]]/[[hypothyroidism]].
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., euthyroid sick syndrome) was associated with higher mortality and increased [[IL-6]], suggesting poor [[prognosis]] in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T20:13:54Z

Mitra Chitsazan: /* Natural History, Complications, and Prognosis */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include:
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including: <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*[[Prognosis]] has generally been good in most cases of [[COVID-19]] patients with [[hyperthyroidism]]/[[hypothyroidism]].
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., euthyroid sick syndrome) was associated with higher mortality and increased [[IL-6]], suggesting poor [[prognosis]] in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T20:13:37Z

Mitra Chitsazan: /* Epidemiology and Demographics */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include:
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including:
*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*[[Prognosis]] has generally been good in most cases of [[COVID-19]] patients with [[hyperthyroidism]]/[[hypothyroidism]].
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., euthyroid sick syndrome) was associated with higher mortality and increased [[IL-6]], suggesting poor [[prognosis]] in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T20:08:05Z

Mitra Chitsazan: /* Natural History, Complications, and Prognosis */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include:
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including:
*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*[[Prognosis]] has generally been good in most cases of [[COVID-19]] patients with [[hyperthyroidism]]/[[hypothyroidism]].
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., euthyroid sick syndrome) was associated with higher mortality and increased [[IL-6]], suggesting poor [[prognosis]] in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T18:20:28Z

Mitra Chitsazan: /* Pathophysiology */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref> <ref name="pmid16060914">{{cite journal| author=Leow MK, Kwek DS, Ng AW, Ong KC, Kaw GJ, Lee LS| title=Hypocortisolism in survivors of severe acute respiratory syndrome (SARS). | journal=Clin Endocrinol (Oxf) | year= 2005 | volume= 63 | issue= 2 | pages= 197-202 | pmid=16060914 | doi=10.1111/j.1365-2265.2005.02325.x | pmc=7188349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16060914 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include:
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including:
*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*Prognosis has generally been good in most cases of COVID-19 patients with hyperthyroidism/hypotheyroidism.
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., Sick euthyroid syndrome) was associated with death and increased IL-6, suggesting poor prognosis in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T18:17:49Z

Mitra Chitsazan: /* History and Symptoms */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include:
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including:
*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*Prognosis has generally been good in most cases of COVID-19 patients with hyperthyroidism/hypotheyroidism.
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., Sick euthyroid syndrome) was associated with death and increased IL-6, suggesting poor prognosis in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]:
* [[Sore throat]]
* [[Periorbital edema]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T18:17:00Z

Mitra Chitsazan: /* Physical Examination */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include:
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including:
*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*Prognosis has generally been good in most cases of COVID-19 patients with hyperthyroidism/hypotheyroidism.
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., Sick euthyroid syndrome) was associated with death and increased IL-6, suggesting poor prognosis in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]
* [[Sore throat]]
* [[Periorbital edema]]

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T18:16:38Z

Mitra Chitsazan: /* Electrocardiogram */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include:
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including:
*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*Prognosis has generally been good in most cases of COVID-19 patients with hyperthyroidism/hypotheyroidism.
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., Sick euthyroid syndrome) was associated with death and increased IL-6, suggesting poor prognosis in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]
* [[Sore throat]]
* [[Periorbital edema]]

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism]] and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T18:16:00Z

Mitra Chitsazan: /* Physical Examination */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include:
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including:
*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*Prognosis has generally been good in most cases of COVID-19 patients with hyperthyroidism/hypotheyroidism.
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., Sick euthyroid syndrome) was associated with death and increased IL-6, suggesting poor prognosis in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]
* [[Sore throat]]
* [[Periorbital edema]]

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

===Physical Examination===
The most common physical examination findings in patients with '''[[hypothyroidism]]''' include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

The most common physical examination findings in patients with '''[[hyperthyroidism]]''' include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism)) and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T18:15:12Z

Mitra Chitsazan: /* Epidemiology and Demographics */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include:
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

* Data on the exact epidemiology and demographics of [[thyroid diseases]] in [[COVID-19]] patients are lacking.
* Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]], [[sick euthyroid syndrome]] have been reported in [[COVID-19]] patients worldwide <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including:
*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*Prognosis has generally been good in most cases of COVID-19 patients with hyperthyroidism/hypotheyroidism.
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., Sick euthyroid syndrome) was associated with death and increased IL-6, suggesting poor prognosis in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]
* [[Sore throat]]
* [[Periorbital edema]]

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

===Physical Examination===
The most common physical examination findings in patients with [[hypothyroidism]] include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

The most common physical examination findings in patients with [[hyperthyroidism]] include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism)) and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T18:12:00Z

Mitra Chitsazan: /* Pathophysiology */

__NOTOC__
{{COVID-19 thyroid disorders}}

{{CMG}} {{AE}}

==Overview==
Coronavirus disease 2019 (COVID-19) is caused by [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]], a novel coronavirus named for the similarity of its [[Symptom|symptoms]] to those caused by the [[severe acute respiratory syndrome]]. Coronavirus disease 2019 (COVID-19) has been considered a global pandemic since its first emergence in Wuhan, China. On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].[[COVID-19]] has been found to affect several organs and body systems, including the [[endocrine system]], with short-term and possible long-term consequences. Recent data shows that [[COVID-19]] patients have experienced a range of [[thyroid diseases]].

==Historical Perspective==
*[[Coronavirus]] disease 2019 ([[COVID-19]]) has been considered as a global [[pandemic]] since its first emergence in Wuhan,China.<ref name="urlWHO Western Pacific | World Health Organization">{{cite web |url=https://www.who.int/westernpacific/emergencies/covid-19 |title=WHO Western Pacific | World Health Organization |format= |work= |accessdate=}}</ref>
*On March 12, 2020, the [[World Health Organization]] declared the [[COVID-19]] outbreak a [[pandemic]].
*In March 2020, the first case of subacute thyroiditis in an 18-year-old woman with COVID-19 was described. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Classification==
There is no established system for the classification of [[COVID-19-associated thyroid disorders]].

==Pathophysiology==
The exact pathogenesis of COVID-19-associated thyroid diseases is not fully understood. However, the following hypotheses have been suggested for the development of thyroid dysfunction in COVID-19 patients. <ref name="pmid33765288">{{cite journal| author=Lisco G, De Tullio A, Jirillo E, Giagulli VA, De Pergola G, Guastamacchia E | display-authors=etal| title=Thyroid and COVID-19: a review on pathophysiological, clinical and organizational aspects. | journal=J Endocrinol Invest | year= 2021 | volume= 44 | issue= 9 | pages= 1801-1814 | pmid=33765288 | doi=10.1007/s40618-021-01554-z | pmc=7992516 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33765288 }} </ref> <ref name="pmid32652001">{{cite journal| author=Lazartigues E, Qadir MMF, Mauvais-Jarvis F| title=Endocrine Significance of SARS-CoV-2's Reliance on ACE2. | journal=Endocrinology | year= 2020 | volume= 161 | issue= 9 | pages= | pmid=32652001 | doi=10.1210/endocr/bqaa108 | pmc=7454499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32652001 }} </ref> <ref name="pmid33241508">{{cite journal| author=Scappaticcio L, Pitoia F, Esposito K, Piccardo A, Trimboli P| title=Impact of COVID-19 on the thyroid gland: an update. | journal=Rev Endocr Metab Disord | year= 2021 | volume= 22 | issue= 4 | pages= 803-815 | pmid=33241508 | doi=10.1007/s11154-020-09615-z | pmc=7688298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33241508 }} </ref> <ref name="pmid26071885">{{cite journal| author=Fliers E, Bianco AC, Langouche L, Boelen A| title=Thyroid function in critically ill patients. | journal=Lancet Diabetes Endocrinol | year= 2015 | volume= 3 | issue= 10 | pages= 816-25 | pmid=26071885 | doi=10.1016/S2213-8587(15)00225-9 | pmc=4979220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26071885 }} </ref> <ref name="pmiddoi:10.1210/clinem/dgaa813">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi:10.1210/clinem/dgaa813 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref>

*[[Angiotensin-converting enzyme 2]] ([[ACE2]]) receptors are essentially involved in [[SARS-CoV-2]] internalization into host cells. The [[thyroid gland]] is amongst the organs which have the highest levels of [[ACE2]] expression and activity. Therefore, following [[SARS-CoV-2]] infection, thyroid damage could result from either a direct or immune-mediated injury.
*[[COVID-19]] may also cause an immune system imbalance and, in severe cases, a [[cytokine storm]], which may break [[immunotolerance]] in susceptible patients, leading to new onset of immune-mediated [[thyroiditis]], exacerbating a previous [[thyroid disease]], or inducing a recurrence of [[thyroid disease]].
*The other potential pathophysiology for the development of [[thyroid disease]] in [[COVID-19]] could be an underlying [[euthyroid sick syndrome]], also known as [[nonthyroidal illness syndrome]] ([[NTIS]]), caused by critical illness. Patients with the [[euthyroid sick syndrome]] are often characterized by low [[T3]] concentration, along with a normal or low serum [[TSH]]. [[T4]] concentration may be low in more severe or prolonged illnesses.
* The fourth hypothesis is that [[hypothalamic]]-[[pituitary]]-[[thyroid]] ([[HPT]]) axis dysfunction in [[COVID-19]] Patients results in a decresaed level of serum [[TSH]] in patients with [[SARS-CoV-2]], causing secondary causes of [[hypothyroidism]] (central hypothyroidism).

==Causes==
[[Coronavirus disease 2019]] ([[COVID-19]]) caused by a novel [[coronavirus]] called [[SARS-CoV-2]] is the cause of [[COVID-19]]-associated [[thyroid diseases]]. To read more click [[COVID-19|here]]

==Differentiating COVID-19-associated thyroid diseases from other Diseases==
* Differential diagnosis of [[hyperthyroidism]] in [[COVID-19]] patients may include:
**[[Graves' disease]]
**[[Subacute thyroiditis]]
** [[Painless thyroiditis]]

* Differential diagnosis of [[hypothyroidism]] in in [[COVID-19]] patients may include:
** Primary hypothyroidism:
***[[Autoimmune thyroiditis]]([[Hashimoto's thyroiditis]])
***[[Subacute granulomatous (de Quervain’s) thyroiditis]]
** [[Secondary hypothyroidism]]
*** [[Central Hypothyroidism]]]
*For a complete list of differential diagnoses of hyperthyroidism, please click [[Hyperthyroidism#Differentiating the causes of thyrotoxicosis|here]].
*For a complete list of differential diagnoses of hypothyroidism, please click [[Hypothyroidism#Differentiating different causes of hypothyroidism|here]].
*For a complete list of differential diagnoses of the euthyroid sick syndrome, please click [[Euthyroid sick syndrom#Differentiating Euthyroid sick syndrome from other Diseases|here]].

==Epidemiology and Demographics==

Several cases of [[subacute thyroiditis]], [[Hashimoto thyroiditis]], [[myxedema coma]], [[Grave's disease]], [[atypical thyroiditis]], [[thyrotoxicosis]] have been reported in COVID-19 patients worldwide <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref> <ref name="pmid32843467">{{cite journal| author=Mattar SAM, Koh SJQ, Rama Chandran S, Cherng BPZ| title=Subacute thyroiditis associated with COVID-19. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 8 | pages= | pmid=32843467 | doi=10.1136/bcr-2020-237336 | pmc=7449350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32843467 }} </ref> <ref name="pmid32504458">{{cite journal| author=Asfuroglu Kalkan E, Ates I| title=A case of subacute thyroiditis associated with Covid-19 infection. | journal=J Endocrinol Invest | year= 2020 | volume= 43 | issue= 8 | pages= 1173-1174 | pmid=32504458 | doi=10.1007/s40618-020-01316-3 | pmc=7273820 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32504458 }} </ref> <ref name="pmid32780854">{{cite journal| author=Brancatella A, Ricci D, Cappellani D, Viola N, Sgrò D, Santini F | display-authors=etal| title=Is Subacute Thyroiditis an Underestimated Manifestation of SARS-CoV-2 Infection? Insights From a Case Series. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 10 | pages= | pmid=32780854 | doi=10.1210/clinem/dgaa537 | pmc=7454668 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32780854 }} </ref> <ref name="pmid33370933">{{cite journal| author=Chakraborty U, Ghosh S, Chandra A, Ray AK| title=Subacute thyroiditis as a presenting manifestation of COVID-19: a report of an exceedingly rare clinical entity. | journal=BMJ Case Rep | year= 2020 | volume= 13 | issue= 12 | pages= | pmid=33370933 | doi=10.1136/bcr-2020-239953 | pmc=7750881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370933 }} </ref> <ref name="pmid33005461">{{cite journal| author=Campos-Barrera E, Alvarez-Cisneros T, Davalos-Fuentes M| title=Subacute Thyroiditis Associated with COVID-19. | journal=Case Rep Endocrinol | year= 2020 | volume= 2020 | issue= | pages= 8891539 | pmid=33005461 | doi=10.1155/2020/8891539 | pmc=7522602 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33005461 }} </ref> <ref name="pmid32668831">{{cite journal| author=Tee LY, Harjanto S, Rosario BH| title=COVID-19 complicated by Hashimoto's thyroiditis. | journal=Singapore Med J | year= 2021 | volume= 62 | issue= 5 | pages= 265 | pmid=32668831 | doi=10.11622/smedj.2020106 | pmc=8801861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32668831 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32984743">{{cite journal| author=Dixit NM, Truong KP, Rabadia SV, Li D, Srivastava PK, Mosaferi T | display-authors=etal| title=Sudden Cardiac Arrest in a Patient With Myxedema Coma and COVID-19. | journal=J Endocr Soc | year= 2020 | volume= 4 | issue= 10 | pages= bvaa130 | pmid=32984743 | doi=10.1210/jendso/bvaa130 | pmc=7499619 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32984743 }} </ref> <ref name="pmid32738929">{{cite journal| author=Muller I, Cannavaro D, Dazzi D, Covelli D, Mantovani G, Muscatello A | display-authors=etal| title=SARS-CoV-2-related atypical thyroiditis. | journal=Lancet Diabetes Endocrinol | year= 2020 | volume= 8 | issue= 9 | pages= 739-741 | pmid=32738929 | doi=10.1016/S2213-8587(20)30266-7 | pmc=7392564 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32738929 }} </ref> <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>

==Risk Factors==
There are no established risk factors for [[COVID-19]]-associated [[thyroid diseases]].

==Screening==
There is insufficient evidence to recommend routine screening for [[COVID-19]]-associated [[thyroid diseases]].

==Natural History, Complications, and Prognosis==
A number of observational studies have shown that [[COVID-19]] infection may be linked to some [[thyroid diseases]], including:
*[[Subacute thyroiditis]]
*[[Graves’ disease]]
*[[Non-thyroidal illness]] or [[euthyroid sick syndrome]]
*[[Thyrotoxicosis]]
*[[Hashimoto’s thyroiditis]]

*Prognosis has generally been good in most cases of COVID-19 patients with hyperthyroidism/hypotheyroidism.
**In a patient with subacute thyroiditis, the thyroid function and inflammatory markers normalized in 40 days. <ref name="pmid32436948">{{cite journal| author=Brancatella A, Ricci D, Viola N, Sgrò D, Santini F, Latrofa F| title=Subacute Thyroiditis After Sars-COV-2 Infection. | journal=J Clin Endocrinol Metab | year= 2020 | volume= 105 | issue= 7 | pages= | pmid=32436948 | doi=10.1210/clinem/dgaa276 | pmc=7314004 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32436948 }} </ref>
*In a study on 154 COVID-19 patients, Low fT3 (i.e., Sick euthyroid syndrome) was associated with death and increased IL-6, suggesting poor prognosis in these patients. <ref name="pmid34760673">{{cite journal| author=Dabas A, Singh H, Goswami B, Kumar K, Dubey A, Jhamb U | display-authors=etal| title=Thyroid Dysfunction in COVID-19. | journal=Indian J Endocrinol Metab | year= 2021 | volume= 25 | issue= 3 | pages= 198-201 | pmid=34760673 | doi=10.4103/ijem.ijem_195_21 | pmc=8547402 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34760673 }} </ref>

==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of COVID-19-associated thyroid diseases is made based on the [[thyroid function test]] ([[TFT]]), which measures serum levels of [[triiodothyronine]] ([[T3]]), [[thyroxine]] ([[T4]]), and [[thyroid stimulating hormone]] ([[TSH]]).

===History and Symptoms===

The symptoms of clinical [[hypothyroidism]] in [[COVID-19]] patients are similar to [[hypothyroidism]] in the general population.
The most common symptoms include:
* [[Fatigue]]
* [[Cold intolerance]]
* Decreased [[sweating]]
* [[Hypothermia]]
* Coarse skin
* [[Weight gain]]
* [[Hoarseness]]
* [[Depression]]
* [[Emotional lability]]
* [[Attention deficit]]
* Puffiness
* [[Hair loss]]
* [[Constipation]]
* Slowed speech and movements
* [[Hyperlipidemia]]
* [[Galactorrhea]]
* [[Myxedema coma]] (with [[Edema|non-pitting edema]])
If accompanied by [[thyroiditis]]
* [[Sore throat]]
* [[Periorbital edema]]

The symptoms of clinical [[hyperthyroidism]] in [[COVID-19]] patients are similar to [[hyperthyroidism]] in the general population.
The most common symptoms include:
* [[Palpitations]]
* [[Insomnia]]
* [[Anxiety]]
* [[Weight loss]]
* [[Heat intolerance]]
* [[Diarrhea]]

===Physical Examination===
The most common physical examination findings in patients with [[hypothyroidism]] include:
* [[Myxedema]]: in patients with Hashimoto's thyroiditis
* [[Bradycardia]]
* [[Dry skin]]
* Coarse hair
* Enlarged [[thyroid gland]] or presence of [[goiter]]
* Small or shrunken [[thyroid gland]] (late in the disease)
*[[Bradypnea]]
* Slowed [[speech]]
* [[Reflexes|Slowed reflexes]]

The most common physical examination findings in patients with [[hyperthyroidism]] include: <ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* [[Tachycardia]]
* [[Stare]]
* [[Eyelid lag]]
* [[Resting tremor]]
* [[Hyperreflexia]]
* Warm, moist, and smooth skin
* In patients with Graves's disease:
** Localized dermopathy (i.e., [[pretibial myxedema]])
** [[Proptosis]] ([[exophthalmos]])
** [[Goiter]]

===Laboratory Findings===
The laboratory findings in '''[[hyperthyroidism]]''' are:
*Elevated levels of [[serum thyroxine]] ([[T4]]) and [[triiodothyronine]] ([[T3]]).
*Undetectable serum TSH.
*Total T4 and T3 measurements are influenced by multiple conditions affecting serum thyroxine-binding globulin (TBG). Thus, measurement of free thyroid hormone; free T4 (FT4) and free T3 (fT3), is the gold standard for the diagnosis of Graves' disease.<ref name="pmid17673120">{{cite journal |vauthors=Dufour DR |title=Laboratory tests of thyroid function: uses and limitations |journal=Endocrinol. Metab. Clin. North Am. |volume=36 |issue=3 |pages=579–94, v |year=2007 |pmid=17673120 |doi=10.1016/j.ecl.2007.04.003 |url=}}</ref>
* Antibodies against the TSH receptor (TRAbs) are pathognomonic for Graves' disease. They are detectable in the serum of about 98% of untreated patients.<ref name="pmid20594972">{{cite journal |vauthors=Zöphel K, Roggenbuck D, Schott M |title=Clinical review about TRAb assay's history |journal=Autoimmun Rev |volume=9 |issue=10 |pages=695–700 |year=2010 |pmid=20594972 |doi=10.1016/j.autrev.2010.05.021 |url=}}</ref> Detection of TRAbs rules out other causes of thyrotoxicosis.<ref name="pmid23539719">{{cite journal |vauthors=Barbesino G, Tomer Y |title=Clinical review: Clinical utility of TSH receptor antibodies |journal=J. Clin. Endocrinol. Metab. |volume=98 |issue=6 |pages=2247–55 |year=2013 |pmid=23539719 |pmc=3667257 |doi=10.1210/jc.2012-4309 |url=}}</ref>
* Anti-thyroid peroxidase (TPO) and antithyroglobulin (Tg) antibodies are also detectable in many patients with Graves' disease, but it is not recommended to measure these antibodies for diagnosis in all patients.

The laboratory findings in '''[[hypothyroidism]]''' are:
*Increased [[Thyroid-stimulating hormone]] (TSH)
*Decreased Free [[T3]] and Free [[T4]]
*[[TSH]] may be decreased in the transient hyperthyroid state<ref>{{cite journal|last=Simmons|first=PJ|title=Antigen-presenting dendritic cells as regulators of the growth of thyrocytes: a role of interleukin-1beta and interleukin-6|journal=Endocrinology|year=1998|volume=139|issue=7|pages=3158–3186|pmid=9645688|doi=10.1210/en.139.7.3148}}</ref>
* Thyroid antibodies are usually positive in patients with Hashimoto's thyroiditis:
** [[thyroid peroxidase|Anti-thyroid peroxidase]] antibodies (anti-TPO) (correlates with the disease severity)
** [[thyroglobulin|Anti-thyroglobulin]] antibodies (anti-Tg)
** [[Antimicrosomal antibody|Anti-microsomal antibodies]] can help obtain an accurate diagnosis<ref>{{cite book |last1= Giannini |first1= AJ |authorlink1= |title= The Biological Foundations of Clinical Psychiatry |url= |year= 1986 |publisher= Medical Examination Publishing Company |location= New Hyde Park, NY |language= |isbn= 0-87488-449-7 |oclc= |doi= |id= |page= |pages= 193–198 |quote= |ref= |bibcode= }}</ref>

The laboratory findings in '''[[euthyroid sick syndrome]]''' are:
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " | Euthyroid sick syndrome
! style="background: #4479BA; color: #FFFFFF; " | T3
(80-180 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | T4
(4.6-12 ug/dl)
! style="background: #4479BA; color: #FFFFFF; " | FT4
(0.7-1.9 ng/dl)
! style="background: #4479BA; color: #FFFFFF; " | TSH
(0.4 to 4.0mIU/L)
! style="background: #4479BA; color: #FFFFFF; " | Reverse T3
'''(90 to 350'''pg/mL)
|-
|Mild euthyroid sick syndrome
|↓
|N
|N
|N
|'''↑'''
|-
|Moderate euthyroid sick syndrome
|↓
|N
|N/↓
|N/↓
|'''↑'''
|-
|Severe euthyroid sick syndrome
|↓
|↓
|N/↓
|↓
|'''↑'''
|-
|Recovery
|N/↓
|N
|N
|N
|N/'''↑'''
|}

===Electrocardiogram===
* There are no [[The electrocardiogram|ECG]] findings associated with [[COVID-19|COVID-1]]9-associated [[thyroid disease]].
* However, the following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hyperthyroidism)) and [[thyrotoxicosis]]:
**[[Sinus tachycardia]]
**[[Atrial fibrillation]] (often in [[elderly]] patients)
**[[Complete heart block]] (rare)
**Changes in [[QT interval]]
* The following findings may be seen on [[The electrocardiogram|ECG]] in patients with [[hypothyroidism]]:
**[[Sinus bradycardia]]
**Prolonged [[QTc interval]]
**Changes in the morphology of the [[T-wave]] and [[QRS duration]]
**Low voltage.

===X-ray===
* There are no x-ray findings associated with [[COVID-19]]-associated [[thyroid diseases]].

===Echocardiography or Ultrasound===

*There are no [[echocardiography]]findings associated with [[COVID-19]]-associated thyroid diseases.
*Thyroid ultrasoongraphy

===CT scan===
*There are no CT scan findings associated with COVID-19-associated thyroid diseases.

===MRI===
* There are no MRI findings associated with COVID-19-associated thyroid diseases.

===Other Imaging Findings===
====Thyroid ultrasound====
*Thyroid ultrasound may help diagnose Graves's disease. Typically, the thyroid pattern in Graves' disease is hypoechoic. Thyroid ultrasound gives an accurate estimation of the thyroid size, which is important in planning the therapeutic management and allows the detection of thyroid nodules that may not be palpable on physical examination.

====Color flow Doppler====
*Color flow Doppler (CFD) estimates the blood flow which, in hyperthyroid Graves' disease patients, is typically increased within the thyroid gland.
*CFD can be useful in the differential diagnosis of Graves' disease and other causes of thyrotoxicosis characterized by a low blood flow to the thyroid, such as factitious thyrotoxicosis, painless and subacute thyroiditis. <ref name="pmid21663420">{{cite journal |vauthors=Kahaly GJ, Bartalena L, Hegedüs L |title=The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective |journal=Thyroid |volume=21 |issue=6 |pages=585–91 |year=2011 |pmid=21663420 |doi=10.1089/thy.2011.2106.ed3 |url=}}</ref>

===Other Diagnostic Studies===
====Radioactive iodine uptake====
* 24-hr radioactive iodine uptake (RAIU) is a diagnostic measure for Graves' disease, which shows increased homogeneous uptake.<ref>{{Cite journal
| author = [[Terry J. Smith]] & [[Laszlo Hegedus]]
| title = Graves' Disease
| journal = [[The New England journal of medicine]]
| volume = 375
| issue = 16
| pages = 1552–1565
| year = 2016
| month = October
| doi = 10.1056/NEJMra1510030
| pmid = 27797318
}}</ref>
* RAIU is generally increased in Graves' disease because of the action of stimulating TRAbs.
* Normal values for RAIU 24 h after the administration of a tracer dose of radioiodine are 20% in iodine sufficient and 40% in iodine-deficient areas.

{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid Disease}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, dermopathy, acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and elevated inflammatory index
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Symptoms and signs of hypothyroidism
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Hashimoto's thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Diffusely enlarged thyroid gland with a heterogeneous echotexture
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;" | early stages: may show increased uptake, late stages: single or multiple areas of reduced uptake (cold spots)
| style="padding: 5px 5px; background: #F5F5F5;" | -
|}

* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]]. 

==Treatment==
===Medical Therapy===
*Treatment of COVID-19-associated thyroid diseases generally depends on the presentation of [[thyroid disease]].
*No specific treatment has been reported for COVID-19-associated thyroid disease.

===Surgery===
Surgery is not a treatment option for patients with COVID-19-associated thyroid diseases.

===Primary Prevention===
There are no established measures for the primary prevention of COVID-19-associated thyroid diseases.

===Secondary Prevention===
There are no established measures for the secondary prevention of COVID-19-associated thyroid diseases.

==References==

COVID-19-associated thyroid diseases

2022-07-22T18:02:15Z

Mitra Chitsazan: /* Differentiating COVID-19-associated thyroid diseases from other Diseases */