Post-COVID-vaccine autoimmune/inflammatory syndrome in response to adjuvants (ASIA syndrome) manifesting as subacute thyroiditis

Excerpt

SAT is a common thyroid-related syndrome in COVID-19 [1]. However, SAT following vaccine for SARS-CoV-2 is rare. Herein, we report the case of a 47-year-old female who presented with fever and neck pain for 2 weeks following the first dose of the ChAdOx1 nCoV-19 (Astra Zeneca) vaccine. The fever was moderate-to-high grade, continuous, and associated with neck pain radiating to the jaw. She also complained of restlessness, difficulty in swallowing and weight loss of 3 kg in this duration. She was febrile and had tachycardia (110/min). Her neck examination showed a tender goitre (WHO grade II) with no palpable lymphandenopathy. Thyroid function tests (TFT) revealed thyrotoxicosis (T3 2.2 ng/ml [N 0.8–2 ng/ml], T4 12.9 µg/dl [N 4–12 µg/dl], TSH 0.06 µIU/ml [N 0.2–4.2µIU/ml]). Thyroid antibodies (antiTPO 11.8 IU/ml [N < 34] and TRAb 1.28 IU/ml [N < 1.75]) were normal. Neck ultrasound showed a bulky thyroid with hypoechoic nodules (1.5 × 1.0 cm in the right and 0.8 × 0.5 cm in the left lobe) without any cystic changes, calcification or increased vascularity. She underwent a pertechnetate (^99mTc–TcO₄⁻) thyroid scan, which revealed no tracer uptake in the thyroid gland (Fig. 1A). Fine-needle aspiration cytology of the right-sided suspicious nodule showed granulomatous inflammation. The patient was diagnosed with SAT and advised 40 mg propranolol daily. She showed a gradual improvement in her restlessness and gained weight, besides having resolution of her neck discomfort. On re-evaluation after 8 weeks, she had complete resolution of her presenting features, with normal TFT (T3 1.09 ng/ml, T4 7.04 µg/dl, and TSH 1.50 µIU/ml). Repeat scan showed improved trapping function (Fig. 1B). The index case depicts a classic case of autoimmune/inflammatory syndrome in response to adjuvants (ASIA syndrome) in a recipient of SARS-Co-V2 following the first dose of the COVID vaccine.

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