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Subacute Thyroiditis after COVID-19: A Literature Review

Yuya AndoDepartment of Internal Medicine, Division of Gastroenterology, Self-Defense Forces Central Hospital, Tokyo, Japan;
Department of Family Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan;

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Yosuke OnoDepartment of General Medicine, National Defense Medical College, Saitama, Japan;

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Azusa SanoDepartment of General Medicine, National Defense Medical College, Saitama, Japan;

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Naoya FujitaDepartment of General Medicine, National Defense Medical College, Saitama, Japan;

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Sachiko OnoDepartment of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

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ABSTRACT.

Subacute thyroiditis (SAT), potentially caused by severe acute respiratory syndrome coronavirus 2 infection, has been reported as a complication of COVID-19 since 2020. The clinical characteristics and outcomes of SAT after COVID-19 remain incompletely defined. Therefore, we aimed to collect and survey case reports of SAT after COVID-19. We performed a systematic search of PubMed/MEDLINE, Web of Science, and Google Scholar. The keywords and MeSH terms used for the searches were “subacute thyroiditis” and “COVID-19.” A total of 38 patients from 26 case reports, case series, and letters on SAT associated with COVID-19 were included and analyzed. The most frequent SAT symptom was neck pain (27 cases), followed by fever (22 cases). Of the 25 cases with information on the duration between onset of COVID-19 symptoms and onset of SAT symptoms, the shortest was simultaneous occurrence, and the longest was 4 months. In most cases, patients developed SAT at several days or weeks after the onset of COVID-19. All patients with SAT recovered with no severe complications or sequelae. Clinicians should be aware of the possibility of SAT development in patients with neck pain and fever following COVID-19. Further research is necessary to determine the relationship between SAT and COVID-19.

INTRODUCTION

The COVID-19 pandemic, caused by SARS-CoV-2, has devastated the world since its emergence in 2019.1 Although the leading cause of death associated with COVID-19 is acute respiratory distress syndrome,2 other complications associated with COVID-19 have been reported, including acute kidney injury, pulmonary embolism, acute myocarditis, and septic shock.3

Currently, subacute thyroiditis (SAT), potentially invoked by SARS-CoV-2 infection, has been reported as a possible complication associated with COVID-19.4,5 SAT can be caused by multiple triggers, including viral infection, post-inflammatory processes, and autoimmunity.6,7 Patients with SAT exhibit fever, neck pain, and a tender diffuse goiter as well as abnormalities in serum thyroid hormones. The clinical characteristics and outcomes of SAT after COVID-19 remain incompletely defined.

In the present study, we gathered information on SAT after COVID-19 from case reports available in digital databases and described its clinical practice patterns, clinical symptoms, and outcomes. We aimed to examine the collected data on SAT after COVID-19 to further understand the relationship between SAT and COVID-19.

METHODS

Oversight and search strategy.

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement,8 we conducted a systematic search of PubMed/MEDLINE, Web of Science, and Google Scholar. References in the selected articles were reviewed manually and crosschecked for other relevant reports. The search of PubMed/MEDLINE was performed with the following MeSH terms: “COVID-19” and “Thyroiditis, Subacute.” The searches in Web of Science and Google Scholar were carried out with the following terms: “COVID-19” and “Subacute thyroiditis.” The full search terms were “COVID-19” [MeSH] AND “Thyroiditis, Subacute” [MeSH] and “COVID-19” AND “Subacute thyroiditis” in PubMed/MEDLINE; (covid) AND (subacute thyroiditis) in Web of Science; and (COVID-19) AND (subacute thyroiditis) AND (case report) in Google Scholar. The quality of the included articles was assessed using the CARE guidelines.9

Selection of case reports.

The inclusion criteria for the case reports were as follows: 1) SARS-CoV-2 infection confirmed in the context, 2) diagnosis of SAT confirmed in the context, 3) article written in English, and 4) article published from 2020 to 2021. Cases were excluded if they had too little information, such as conference abstracts or autopsy reports only, or if they were duplicated. When results from a case were reported more than twice, the most recent case report was used. All case reports identified in the databases were screened for eligibility on title and abstract.

Extraction of clinical information.

Y. A. conducted the extraction of clinical information from the literature with the assistance of Y. O. Data extracted for the cases included sex, age, past medical history of thyroid disease, race, onset date of COVID-19 symptoms, duration of COVID-19 symptoms, duration between onset of COVID-19 symptoms and onset of SAT symptoms, COVID-19 management, SAT management, steroid usage, information on recovery, and prognosis (died or survived).

RESULTS

We identified 1,379 articles in our digital searches. After reviewing the titles and abstracts and excluding duplicates, we identified 38 cases in 26 articles published up to the end of December 2021.4,5,1033 A flow chart of the article selection process is shown in Figure 1, and an overview of the 38 cases included in the study is provided in Table 1. The quality of the 15 case reports, four case series, six (scientific) letters, and one brief report was assessed and scored using the CARE guideline checklist (Supplemental Table 1).9 All 26 articles contained patient demographic information and diagnosis of SAT after COVID-19.

Figure 1.
Figure 1.

Flow chart of the case report selection process.

Citation: The American Journal of Tropical Medicine and Hygiene 107, 5; 10.4269/ajtmh.21-1223

Table 1

Clinical characteristics of the patients with post–COVID-19 subacute thyroiditis

Ref no. Age/ sex Date of COVID-19 symptom onset or swab positivity COVID-19 symptoms Duration of COVID-19 symptoms Severity Treatment of COVID-19 Date of SAT onset after COVID-19 Duration between onset of COVID-19 symptoms and onset of SAT symptoms SAT symptoms Elevated inflammatory markers at SAT onset Treatment of SAT Steroid tapering or reduction Symptom relief from SAT onset
4 38/F March 1, 2020 Fever (37.5°C), rhinorrhea, anosmia, asthenia 4 days Mild n/a March 17, 2020 16 days Neck pain, asthenia, fever (38.5°C), palpitation, anorexia ESR, CRP Prednisone 25 mg/day “At last evaluation (on May 10), while taking prednisone 15 mg/day, the patient was asymptomatic” “Symptoms disappeared within a few days”
4 29/F March 3, 2020 Rhinorrhea 3 days Mild n/a April 2, 2020 30 days Neck pain, asthenia, palpitation, sweating, fever (37.2°C) ESR, CRP Prednisone 25 mg/day Propranolol 40 mg/day “At last evaluation (on May 18), while taking 15 mg/day of prednisone, the patient was asymptomatic” “Neck pain and fever disappeared within 3 days and the other symptoms within 2 weeks”
4 29/F March 17, 2020 Fever (38.0°C), cough, rhinorrhea, anosmia, diarrhea 14 days Mild n/a April 22, 2020 36 days Neck pain, palpitation, tachycardia, sweating, n/a Ibuprofen 600 mg/day n/a “Symptoms disappeared within 2 weeks”
4 46/F April 3, 2020 Fever (38.2°C), cough, rhinorrhea, anosmia, asthenia 6 days Mild n/a May 2, 2020 20 days Neck pain, fever (37.2°c), palpitation, asthenia, insomnia, anxiety, weight loss CRP Prednisone 25 mg/day “At the last evaluation (on June 15), while taking 20 mg/day of prednisone, the patient was asymptomatic” “Neck pain and fever disappeared within a few days and other symptoms within 2 weeks”
5 69/F n/a Mild fever, cough, dyspnea n/a Moderate Hydroxychloroquine, lopinavir, ritonavir, low-flow oxygen therapy n/a 5 days after initiation of treatment of COVID-19 Palpitation, insomnia, agitation n/a Methylprednisolone 40 mg/day “then continuing with 25 mg oral prednisone, to be progressively tapered over 4 weeks or more, according to clinical response” “Within a few days, symptoms markedly improved”
10 18/F February 28, 2020 Fever (37.5°C), rhinorrhea, cough, fatigue 4 days Mild No treatment March 17, 2020 18 days Fever (37.5°C), fatigue, neck pain, palpitation ESR, CRP, WBC Prednisone 25 mg/day “Steroid was progressively tapered and at the last evaluation (April 27) while taking prednisone 16 mg/day, the patient was asymptomatic” “Neck pain and fever disappeared within 2 days and the remaining symptoms within 1 week”
11 37/F April 10, 2020 Odynophagia, anosmia 1 day Mild Symptomatic treatment n/a “A month after her initial presentation” Neck pain, fatigue ESR, CRP n/a n/a “During her follow-up visit one month after diagnosis, the patient has remained asymptomatic”
12 49/M n/a Sore throat, fever, cough, shortness of breath n/a Moderate Hydroxychloroquine 200 mg twice daily, enoxaparin 0.4 mL once daily n/a 10 days post-discharge from infection control facility for COVID-19 Sore throat, swallowing difficulty, fever (38.3°c), “tonsils were hyperemic” ESR, CRP, WBC Methylprednisolone 32 mg/day “steroid dose was gradually decreased and was planned to be completed in 4 weeks and called for control 1 month after.” “At 1-week post-treatment, the patient was asymptomatic”
13 41/F n/a Fever (38.5°C), neck pain n/a Mild Hydroxychloroquine tablet 200 mg twice daily for 5 days n/a n/a Fever (38.5°C), neck pain ESR, CRP, WBC Prednisolone 16 mg/day “She was discharged on prednisolone tapering dose for 4 weeks” “Prednisolone 16 mg daily was given and she showed significant improvement of clinical condition”
14 41/F n/a Fever, cough, coryza n/a Mild Oral azithromycin, supportive therapy n/a 4 weeks Neck pain, fever (39.5°c), odynophagia, chills, diaphoresis, weight loss (6 kg), fatigue, alopecia, heat intolerance, irritability, headaches, bilateral hand tremors, palpitation ESR, CRP Ibuprofen 600 mg (every 6 h), prednisone 40 mg/day “She completed a 4-week corticosteroid taper” “complete symptom resolution at her last outpatient follow-up visit 45 days from hospital discharge (2 days of hospitalization)”
15 34/M n/a Fever, dry cough, headache, anosmia, sore throat n/a Mild Paracetamol, dequalinium lozenges n/a 9 days Neck pain, tachycardia CRP, WBC Prednisolone 20 mg/day, atenolol 25 mg/day “A steroid-tapering regimen was planned for him to decrease the dosage of prednisone to the minimum required for symptomatic relief with periodic monitoring of thyroid function.” “He was reviewed after 10 weeks in the outpatient clinic. He had completed his tapering course of steroids and was clinically well with no symptoms.”
16 28/F April 15, 2020 Diarrhea, abdominal pain n/a Mild n/a May 14, 2020 29 days Fever (38.5°C), neck pain, sore throat, palpitation, asthenia ESR, CRP, WBC Aspirin 500 mg (every 6 h), propranolol 40 mg (every 6 h) n/a “Symptoms improved in 24 h, with a total relief in 2 weeks”
17 43/F Beginning of March 2020” Fever, rhinorrhea, painful swallowing, cough, hoarseness, conjunctivitis n/a Mild No specific treatment Mid-April 2020 6 weeks Fever (37.5°C), pain and tenderness in the anterior cervical region, fatigue, tremors, palpitation n/a Prednisone 25 mg/day “25 mg/day as the starting dose, gradually tapered” “4 weeks after starting steroid therapy, all thyroid functional tests normalized, as well as inflammatory indexes”
18 47/F n/a “She did not have fever or respiratory symptoms but had right lower lobe pneumonia on chest radiograph” n/a Mild Oral hydroxychloroquine, intravenous ceftriaxone n/a n/a Anterior neck pain CRP Mefenamic acid, celecoxib n/a “The patient reported full resolution of symptoms a month later.”
19 26/F n/a Dry cough 1 week Mild n/a n/a n/a Fever, fatigue, palpitation, anterior neck pain CRP, ESR, WBC n/a n/a n/a
19 37/F n/a Myalgia Few days Mild n/a n/a n/a Fever, fatigue, palpitation, anterior neck pain CRP, ESR, WBC n/a n/a n/a
19 35/M n/a No symptoms n/a Mild n/a n/a n/a Fever, fatigue, palpitation, anterior neck pain CRP, ESR, WBC n/a n/a n/a
19 41/F n/a Low-grade fever, mild myalgia Few days Mild n/a n/a n/a Fever, fatigue, palpitation, anterior neck pain CRP, ESR, WBC n/a n/a n/a
19 52/M n/a Low-grade fever, dry cough, mild myalgia Few days Mild n/a n/a n/a Fever, fatigue, palpitation, anterior neck pain CRP, ESR, WBC n/a n/a n/a
19 34/F n/a No symptoms n/a Mild n/a n/a n/a Fever, fatigue, palpitation, anterior neck pain CRP, ESR, WBC n/a n/a n/a
20 64/M n/a Oppressive chest pain, fever, productive cough, headache, fatigue 14 days Moderate Steroids, azithromycin, Acetaminophen n/a “Three weeks after the first positive PCR test for COVID-19” Distal tremor, diaphoresis Ferritin Atenolol 50 mg twice daily, prednisone 50 mg “gradual dosage tapering over the course of 2 weeks” “Three days after admission, the patient was discharged with full clinical relief. On his last outpatient visit to the endocrine clinic, he had discontinued steroids. His thyroid tests revealed a slight primary hypothyroidism, which was treated with 100 μg of levothyroxine.”
21 58/M June 6, 2020 Fever, myalgia, fatigue n/a Moderate Azithromycin, paracetamol June 12, 2020 6 days Fever, fatigue, delirium, staring gaze, weakness, weight loss, tender thyroid, odynophagia, tachycardia ESR, CRP, WBC, ferritin Dexamethasone (4 mg), naproxen oral prednisolone (15 mg) “Stepwise tapering off” 8 days
22 37/M n/a Cough, chills, fever, dyspnea 7 days Mild Supportive care n/a 1 month Anterior neck pain, fatigue, chills, postural tremor, palmar erythema, tachycardia ESR, CRP Aspirin, propranolol n/a 1 week hypothyroidism
23 58/M n/a n/a n/a Mild Analgesics, favipiravir, azithromycin, zinc tablets, vitamin c capsules n/a n/a Fever, tachycardia, neck pain, increased stool frequency ESR, CRP Prednisolone 30 mg/day, propranolol 40 mg/day “gradually tapered over next 1 month and then stopped” Hypothyroidism
24 44/M n/a Shortness of breath, loose stools, fatigue, hypoxia, fever, dyspnea 5 months Severe 15 L of oxygen, intravenous antibiotics and fluids n/a n/a Malaise, odynophagia, neck pain ESR, CRP, WBC Propranolol 40 mg, paracetamol, ibuprofen n/a 6 weeks
25 45/F n/a Nasal congestion, cough, weakness, muscle pain, headache 7 days Moderate “Symptomatic and antibacterial therapy” n/a 30 days Neck pain, fever, myalgia, palpitation, sweating, tachycardia ESR, WBC Prednisone 30 mg/day “Reduction in the dosage by 5 mg weekly” Within a week
25 40/F n/a n/a n/a Moderate n/a n/a 30 days Neck pain, fever, palpitation, tachycardia CRP, ESR, WBC Prednisone 30 mg/day “Reduction in the dosage by 5 mg weekly” Within a week
26 29/F n/a n/a n/a n/a Azithromycin, hydroxychloroquine n/a 7 weeks Fever, odynophagia, tachycardia, shortness of breath, weight loss, anterior neck tenderness, hand tremor ESR, CRP Prednisone 20 mg/day, atenolol 25 mg/day; “her prednisone was increased to 40 mg and atenolol to 50 mg daily” “The prednisone was gradually tapered off over six weeks” “The patient remained asymptomatic at ten weeks follow up”
27 39/M n/a Sore throat, fatigue, fever 7 days Mild Favipiravir December 28, 2020 n/a Neck pain, fatigue, muscle pain, palpitation, tremors, sinus tachycardia ESR, CRP, WBC Prednisolone 16 mg/day, ibuprofen 1200 mg/day, propranolol 20 mg tid “reduced consecutively” 1 week
28 31/F n/a Fever, painful sore throat n/a Mild “No specific treatment” n/a 2 weeks Anterior neck pain, fever, malaise CRP, ESR, WBC NSAIDs, prednisolone 15 mg/day 7 weeks 1 day
29 41/F September 15, 2020 Headache, fatigue, loss of appetite, fever n/a Mild “Symptomatic treatment” n/a 6 weeks Palpitation, insomnia n/a n/a n/a “Three weeks later, she developed hypothyroidism”
30 67/M n/a Shortness of breath, diarrhea n/a Severe Ceftriaxone, azithromycin n/a n/a Arrhythmia, weight loss, fatigue, diarrhea ESR, CRP Prednisone 20 mg/day 9 months n/a
31 33/M September 23, 2020 Fever (39°C), sore throat, body aches, lethargy, chills, sweating, dry cough, tachycardia n/a Moderate Acetaminophen, naproxen, diphenhydramine, remdesivir, enoxaparin October 2, 2020 9 days Sore throat, neck tenderness ESR, CRP, IL-6 Dexamethasone 4 mg every 8 hours for 5 days, prednisone 25 mg/day “He was discharged with oral prednisone 25 mg daily with taper prescribed” 7 weeks
32 50/M October 6, 2020 Neck pain, fever (39°C), headaches, cough, malaise, loss of smell, retrosternal discomfort n/a n/a Azithromycin Amoxicillin Dexamethasone 6 October 2020 Simultaneously Fever, cough, headache, insomnia, neck pain, hard neck tumor CRP, ESR Prednisone Gradual dose reduction “No symptom recurrence was observed for 10 months of follow-up”
32 39/F December 2020 Cough, headache, fever, malaise n/a n/a n/a n/a 4 weeks Neck pain, tachycardia, insomnia, tremor, fever CRP, ESR Prednisone 60 mg/day 4 months “No recurrence was observed for the 8 months of follow-up”
32 55/F n/a “typical clinical symptoms” n/a n/a n/a n/a 5 weeks Neck pain, fever CRP, ESR Prednisone n/a n/a
32 57/F October 2020 “The disease course was mild with common symptoms” n/a n/a n/a n/a 4 months Neck pain, fever, tachycardia, mood change CRP, ESR Prednisone 40 mg/day “Gradual dose reduction” n/a
33 46/F n/a Asymptomatic n/a Mild Untreated n/a n/a Neck pain, earache, fever, malaise, insomnia ESR NSAIDs, prednisone 40 mg/day Six weeks Two weeks

CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; F = female; IL-6, interleukin-6; M = male; n/a = not available; NSAID = nonsteroidal antiinflammtory drug; PCR = polymerase chain reaction; Ref = reference; SAT = subacute thyroiditis; WBC = white blood cell count.

Of the 38 patients with SAT after COVID-19, 25 were women. In the four case reports that described patient race, two patients were Caucasian and two were Asian. Among the total patients, two had past medical history of thyroid disease, described as nontoxic goiter. We confirmed SARS-CoV-2 infection in the context from a swab or laboratory examination in 20 cases. COVID-19 symptoms were confirmed for 32 cases. The most frequent COVID-19 symptom was fever (22 cases). Three cases were described as asymptomatic. Three case reports did not describe the COVID-19 symptoms. On the basis of the living guidance for clinical management of COVID-19 provided by the WHO,34 23 cases were categorized as mild, seven cases as moderate, and two as severe.

All reports for the 38 cases described SAT symptoms. The most frequent SAT symptom was neck pain (27 cases), followed by fever (22 cases). Of the 25 cases with information on the duration between onset of COVID-19 symptoms and onset of SAT symptoms, as mentioned in the text or able to be calculated, the shortest was simultaneous occurrence (0 days) and the longest was 4 months. In most cases, patients developed SAT at several days or weeks after the onset of COVID-19.

We confirmed that the thyroid state was described for 22 cases. Enlarged thyroid was the most common state (11 cases), followed by any tenderness (nine cases). We further confirmed that 37 patients had thyrotoxicosis, evaluated by detection of free T4, free T3, or thyroid-stimulating hormone. One article did not mention the actual serum levels of thyroid hormones, but we concluded that the patient experienced SAT from the following text: “Thyroid function tests were consistent with subclinical hypothyroidism.”4 The states for thyroglobulin, thyroglobulin antibody, antithyroid peroxidase antibody, and thyroid-stimulating hormone receptor antibody were mentioned in 27 cases. We further extracted the results of biological examinations reported for 35 cases. Of these 35 cases, 31 cases had increased C-reactive protein, and 30 cases had confirmed elevation of erythrocyte sedimentation rate. Interleukin-6 was measured in only one case and was found to be elevated.31 Ultrasound analysis of the thyroid was carried out in 14 cases and revealed hypoechoic areas in an enlarged thyroid in most cases. These findings were consistent with SAT.

Management of SAT was reported for 30 cases. Twenty-five patients were treated with corticosteroids such as prednisone. All patients recovered from both COVID-19 and SAT, although four patients suffered from hypothyroidism after SAT.20,22,23,29

DISCUSSION

In this study, we analyzed 38 cases of SAT after COVID-19. Most patients developed SAT at several days or weeks after the onset of COVID-19. However, some cases had onset of SAT at several months after the onset of COVID-19. In most SAT cases, the severity of COVID-19 was categorized as mild. The symptoms associated with SAT were similar to those previously reported for typical SAT cases.35,36 Although four patients suffered from hypothyroidism after SAT, none of the patients died of SAT.

We found that the clinical characteristics of SAT after COVID-19 were similar to those of typical SAT. In general, young female adults are commonly affected by SAT,36,37 and the cases in the present study were consistent with this trend. The present study also demonstrated that the biological data for SAT after COVID-19 resembled those for typical SAT. These similarities suggest that SAT associated with COVID-19 may occur with the same pathophysiology as typical SAT, including viral infection, post-inflammatory processes, and autoimmunity. To date, the incidence rate of SAT after COVID-19 remains unknown. Further epidemiological research should be undertaken to determine the relationship between SAT and COVID-19.

Our study showed that SAT can develop regardless of the severity of COVID-19. Previous reports indicated the importance of IL-6 in the cytokine storm associated with COVID-19.38,39 Direct damage to the thyroid gland was also hypothesized.40 However, in most SAT patients, the severity of COVID-19 was categorized as mild or moderate.

Most patients with SAT were treated with steroids, followed by gradual tapering over several months. It is noteworthy that all the patients in our study became asymptomatic within several months. Previous reports described that some patients with COVID-19 had sequelae, such as fatigue, dyspnea, chest pain, and cough.41,42 Patients with COVID-19 can also have psychological or cognitive symptoms.43,44 In our study, all patients with SAT following COVID-19 had no remarkable sequelae after their recovery.

Thyroid and COVID-19.

Currently, several reports have suggested an underlying relationship between the thyroid and COVID-19. Expression of angiotensin-converting enzyme 2 receptor was detected in the thyroid,45,46 leading to a hypothesis that SARS-CoV-2 directly infects the thyroid tissue.47 This may arise because angiotensin-converting enzyme 2 receptor and cellular protease TMPRSS2 are the SARS-CoV-2 entry requirements for infection.48,49 Some researchers mentioned the anatomical location of the thyroid, being near the front of the airway and lying against and around the front of the larynx and trachea.47,50 Specifically, this anatomical location can provide an easy entry point for the virus.

Strengths and limitations.

The strength of our study is the relatively large number of cases compared with previous studies because we accumulated cases until the end of December 2021. In addition, the WHO staging was applied.34 Our study showed that SAT can occur regardless of the severity of COVID-19, thus alerting physicians that SAT can develop under COVID-19 therapy.

The present study has some limitations. First, the number of cases collected was too small to reach a conclusion on the relationship between SAT and COVID-19. Second, the descriptive quality of the case reports was heterogeneous, which made it difficult to review the reports comprehensively. Because the effect of publication bias was strong and statistical analysis will result in low generalizability, we refrained from conducting statistical analyses. Third, publication bias could be inevitable in this research because there are likely unpublished cases of SAT after COVID-19. This may arise because SAT is not always critical and may be overlooked by physicians. Finally, bias arising from the database or language choices may have affected the case selection.

Nevertheless, given the increasing numbers of COVID-19 cases worldwide, it is estimated that the number of cases with SAT after COVID-19 infection will increase. The present research enables physicians to consider certain clinical implications, such as when to suspect SAT in COVID-19 patients or when to prescribe agents. In addition, we suggest the importance of monitoring serum levels of thyroid hormones in COVID-19 patients.

Conclusion.

In conclusion, SAT may develop days or weeks after the onset of COVID-19. The clinical features of SAT after COVID-19 were similar to those of typical SAT, and in most cases, the patients achieved complete remission using steroids without sequelae. Clinicians should be aware of the possibility of SAT in patients with neck pain and fever after COVID-19.

Supplemental Materials

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ACKNOWLEDGMENTS

We thank Alison Sherwin, PhD, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript. The American Society of Tropical Medicine and Hygiene has waived the Open Access fee for this article due to the ongoing COVID-19 pandemic.

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Author Notes

Address correspondence to Yosuke Ono, Department of General Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan. E-mail: onoyousuke1979@yahoo.co.jp

Authors’ addresses: Yuya Ando, Department of Internal Medicine, Division of Gastroenterology, Self-Defense Forces Central Hospital, Tokyo, Japan, and Department of Family Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan, E-mail: yuusai.4869holmes@gmail.com. Yosuke Ono*, Azusa Sano, and Naoya Fujita, Department of General Medicine, National Defense Medical College, Saitama, Japan, E-mails: onoyousuke1979@yahoo.co.jp, sanoazusa430@gmail.com, and raoh0615@gmail.com. Sachiko Ono, Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan, E-mail: sachico315@m.u-tokyo.ac.jp.

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