1 Introduction
2 Pathogenesis
2.1 Genetic background
2.2 Triggering factors
3 Epidemiology
4 Current clinical manifestation and factors modifying clinical course
4.1 The hitherto state-of-art
4.2 Novel aspects of the clinical and laboratory manifestation
4.3 Significance of HLA-background
4.3.1 Clinical manifestation
4.3.2 US pattern
4.3.3 Risk of recurrence
4.4 Significance of a viral factor–SARS-CoV-2
4.4.1 The first case report
4.4.2 The time-lag between SARS-CoV-2 infection and SAT symptoms
4.4.3 Clinical symptoms of SAT triggered by COVID-19
4.4.4 The most important clinical management recommendations related to SAT triggered by COVID-19
5 The most important diagnostic problems
5.1 False negative diagnosis
5.2 False positive diagnosis
5.3 Co-presence of SAT and thyroid malignancy
6 Diagnostic criteria adapted to the current knowledge
Main criteria (all should be met) | Additional criteria (at least one should be met): |
---|---|
1. Laboratory: elevation of ESR or at least CRP 2. Ultrasound: hypoechoic area/areas with blurred margin and decreased vascularization in US* | 1. Hard thyroid swelling 2. Pain and tenderness of the thyroid gland/lobe 3. Elevation of serum FT4 and suppression of TSH 4. Decreased radioiodine uptake 5. FNAB result typical for SAT |
*FNAB should be performed in all doubtful cases and in patients that show no improvement on a short term follow-up, in order to exclude malignancy | |
Remarks related to COVID-19 pandemic (should be taken into account during pandemic) | |
1. SAT diagnosis should be considered in patients with/after SARS-CoV-2 infections with: 1.1 unexpected: 1.1.1 de novo presence of tachycardia or arrhythmias 1.1.2 deterioration of previously present tachycardia or arrhythmias 1.1.3 deterioration of fatigue/malaise 1.2 laboratory markers of thyrotoxicosis, including decreased TSH and increased FT4 – thyroid tests should be considered in all patients hospitalized due to COVID-19, especially in ICU patients | |
2. SAT is more frequently painless in COVID-19 patients and the presence of pain should not be treated as SAT criterion in this group, especially in hospitalized patients | |
3. As SAT may be the only manifestation of COVID-19, testing for SARS-CoV2 infection should be considered in all patients with SAT diagnosed during the pandemic |
7 Novel aspects of the treatment
8 Summary
Novel findings | Clinical implication | |
---|---|---|
Genetic background | High risk alleles [10]: | Testing towards these four alleles can provide information about the SAT susceptibility (data for Caucasian population) [10] |
• HLA-B*35:01/02/03 | ||
• HLA-C*04:01 | ||
• HLA-B*18:01 | ||
• HLA-DRB1*01 | ||
Triggering factors | 1. Viral: • SARS-CoV-2 [49] | 1. SARS-CoV-2 infection may trigger unexpected number of SAT cases – medical care providers should be aware of such possibility and of differences in SAT clinical course |
2. Non-viral: | 2. Medical stuff should inform patients about the risk and about signs and symptoms of SAT | |
Epidemiology | 1. Consider thyroid hormone testing and/or other SAT screening methods especially in ICU patients | |
2. Physicians should be aware about possible SAT occurrence in children; possible atypical course with trachea compression [31] | ||
Clinical course | 1. More frequent painless course: • >6% in Caucasian population [29] | 1. Neck pain cannot be considered the main symptom or main diagnostic SAT criterion |
2. Possible presence of aTPO, aTg or even TRAb [29] | ||
HLA correlations with clinical course | 1. Clinical manifestation of SAT in patients with co-presence of GD depends on constellation of specific HLA alleles [37] | Clinicians should be aware of these correlations to properly conduct the diagnostic process |
2. US pattern depends on the presence of HLA-B*18:01 [45] | ||
Clinical course of SAT triggered by COVID-19 | 1. Thyroid hormone testing should be considered in COVID-19 hospitalized patients | |
2. If any symptoms are present, SAT should be suspected even during a current active COVID-19 | ||
3. Pain is not a diagnostic criterion in COVID-19 patients, especially in hospitalized ones | ||
4. In COVID-19 patients with tachycardia/ arrhythmias or unexpected deterioration of clinical condition, SAT should be suspected | ||
5. Low TSH and FT3 with elevated FT4 are typical for SAT in COVID-19 patients hospitalized in ICU [18], low TSH with high FT3 and FT4 are typical for SAT in patients with less severe COVID-19 | 5. Thyroid tests should be performed in COVID-19 patients with SAT-like symptoms and should be considered in all hospitalized patients, especially in ICU | |
6. SAT may be the only manifestation of SARS-CoV-2 infection [50] | 6. Testing for SARS-CoV-2 infection should be considered in all patients with SAT diagnosed during pandemic | |
Malignancy-related diagnostic problems | 1. US is mandatory for SAT diagnosis, FNAB recommended in all doubtful cases [64] | |
2. US monitoring of SAT patients is required |