Repeat COVID-19 vaccination safe for adults with vaccine-induced subacute thyroiditis
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Future COVID-19 vaccination doses are safe for adults who previously had a COVID-19 vaccine-induced subacute thyroiditis, according to study data published in The Journal of Clinical Endocrinology & Metabolism.
“All SARS-CoV-2 vaccines can cause subacute thyroiditis, either as a new-onset disease or a recurrence of a previously diagnosed classical subacute thyroiditis. However, only mRNA and adenovirus-vectored SARS-CoV-2 vaccine-induced new-onset or relapsed Graves’ disease cases have been reported to date,” Uur Ünlütürk, MD, associate professor in the division of endocrinology and metabolism, department of internal medicine at Hacettepe University School of Medicine in Ankara, Turkey, and colleagues wrote. “A longer follow-up period allowed us, at least in part, to determine the duration of medical treatment and recovery time and also to gain insight into the safety of repeated vaccinations regarding thyroiditis relapse. ... Revaccinations appear to be safe in patients with SARS-CoV-2 vaccine-induced subacute thyroiditis cases, while more evidence is needed regarding SARS-CoV-2 vaccine-induced Graves’ disease.”
Researchers analyzed data from 19 adults diagnosed with subacute thyroiditis or Graves’ disease who developed symptoms within 4 weeks of receiving a COVID-19 vaccine between January and October 2021. Participants were diagnosed according to the American Thyroid Association’s guidelines from 2016. Remission of subacute thyroiditis was defined as the absence of symptoms, discontinuation of medical treatment, normalization of both thyroid function tests and laboratory indicators of inflammation, and resolution of ultrasonography findings. Remission of Graves’ disease was defined as the absence of symptoms, normalization of thyroid function tests and cessation of antithyroid medical treatment for at least 1 year. Researchers collected demographics, medical history, the type of COVID-19 vaccine received, period of time from vaccination to the development of symptoms, time from symptom onset to diagnosis, and the type and duration of medical treatment.
Repeat vaccination safe after subacute thyroiditis
Of the study cohort, 15 were diagnosed with subacute thyroiditis (median age, 46 years; 93.3% women). Of those diagnosed with subacute thyroiditis, six had a history of thyroid disease, four had a nodular goiter and three were diagnosed with subacute thyroiditis 45 days to 2 months before vaccination. Eight of the 15 adults received the BNT162b2 vaccine (Pfizer-BioNTech).
The median duration from time of vaccination to symptom onset was 7 days, and the median diagnostic delay was 3 weeks. Seven adults were treated with glucocorticoids, four were treated with NSAIDs alone and four received no medical treatment. The median duration of treatment was 26.5 days. At the time the study was written, two-thirds of adults were in remission, with a median duration from symptom onset to remission of 11.5 weeks.
Nine adults with vaccine-induced subacute thyroiditis received a repeat dose of COVID-19 vaccines after diagnosis. Of those, two had symptoms consistent with subacute thyroiditis that intensified after the second dose.
More research needed for repeat vaccination with Graves’ disease
Four adults in the cohort were diagnosed with Graves’ disease (median age, 41.5 years; 75% women) after COVID-19 vaccination. Two of the participants had a history of thyroid disease, one had a nodular goiter and one had primary hypothyroidism associated with Hashimoto’s disease.
The median duration from vaccination to symptom onset was 11.5 days. All four adults developed Graves’ disease after receiving the BNT162b2 vaccine as either a first dose or booster. Two participants were administered methimazole and were still receiving treatment when the study was being written, whereas the other two received no treatment and were in remission at the conclusion of the analysis. One of the participants who was in remission received a repeat dose of BNT162b2 and had no relapse in symptoms or signs of Graves’ disease.
“Given the potentially catastrophic consequences of COVID-19, the development of adverse events should not discourage physicians from offering vaccinations against SARS-CoV-2, including repeat doses,” the researchers wrote. “Instead, it is essential to consider thyroiditis and check thyroid function tests in patients who develop symptoms that might be compatible with subacute thyroiditis or Graves’ disease soon after vaccination.”
Perspective
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Several case reports and case series have emerged documenting new or recurrent subacute thyroiditis or Graves’ hyperthyroidism that appear to have been triggered by vaccination against SARS-CoV-2. This is the first study to assess the risk for recurrent subacute thyroiditis or Graves’ disease following repeated vaccinations.
Cases were rigorously defined and had to occur within 4 weeks of vaccine administration. It is highly reassuring that subacute thyroiditis was typically mild and self-limited, and that most patients (seven of nine) with prior vaccine-linked subacute thyroiditis did not develop recurrent thyroiditis after subsequent vaccine doses. The number of reported patients with vaccine-triggered Graves’ disease is too small to draw conclusions about the likelihood of recurrence or worsening with subsequent vaccine doses.
Overall, while the true incidence of post-vaccination thyroid disease is unknown, it is likely to be relatively rare given that over 12 billion SARS-CoV-2 vaccine doses have been administered worldwide and only sporadic thyroid cases have been reported. It is important to note that thyroiditis and Graves’ hyperthyroidism have also been observed to occur as sequelae of infection with COVID-19. The occasional cases of thyroid disease seen following vaccination against SARS-CoV-2 should not be a reason for vaccine hesitancy, even among those with a prior history of subacute thyroiditis or Graves’ hyperthyroidism. However thyroid function should be assessed post-vaccination in patients with anterior neck pain or symptoms suggesting thyrotoxicosis.
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