Abstract #1004280: Severe Hypothyroidism Associated with COVID-19: A Two Case Presentation

Abstract

In January 2020, a new betacoronavirus strain (SARS-CoV-2) was identified and established as the cause of the coronavirus disease 2019 (COVID-19) that started in China. On March 2020, COVID-19 was declared a global pandemic, affecting millions worldwide. Patients with COVID-19 have been described to present pulmonary and systemic manifestations, including endocrinologic alterations and associations such as altered thyroid function. We present two female patients, both COVID-19 positive, with symptoms of severe hypothyroidism. Patient 1 is 36 years old and patient 2 is 46 years old, both known for hypothyroidism treated with levothyroxine (50 and 100mcg PO/day respectively). Both patients assisted to the emergency room with history of dry cough, ageusia, anosmia, fever and dyspnea, thick and dry scaly skin, bipalpebral edema and pallor. Patient 1 referred myalgias and arthralgias, while patient 2 referred diarrhea. Patient 1 was found with slow and slurred speech, requiring oxygen at arrival, with bilateral basal crackles, left basal hypoventilation and diminished heart sounds; Patient 2 had bilateral lung hypoventilation and asterixis. Both were anemic and presented a positive COVID-19 RT-PCR test. Laboratory results: Patient 1: TSH: 30.5 IU/ml, FT4: < 0.3 mg/dl, Patient 2: TSH: 55.7IU/ml, FT4: 0.59 mg/dl. Chest CT showed cardiomegaly, pleural and pericardial effusions with bilateral peribronchial consolidations for patient 1, and cardiomegaly (at expense of left chambers), bilateral pleural effusion and basal reticular pattern with no shattered glass pattern for patient 2. Patient 2 was diagnosed with chronic kidney disease that needed dialysis. Both patients were treated with Levothyroxine 200mcg PO daily and IV steroids, and patient 1 was diagnosed with myxedematous coma. To this date, there is not enough data to support that thyroid disease increases the risk of having COVID-19, and COVID-19 has not been found with a greater prevalence in patients with thyroid disease. Zhang et al reported a 140-case series of COVID-19 patients, in which 5 patients were known for hypothyroidism (4 presented severe disease). Wang et al reported that serum T3 and T4 were decreased in these patients, being significantly lower than in the control healthy group. Our patients were found with low FT4 and high serum TSH, with symptoms suggesting myxedematous coma and severe hypothyroidism respectively. Pituitary insufficiency has been described in COVID-19 patients, which can lead to thyroid and adrenal insufficiency requiring hormonal replacement therapy, describing the case of our patients in which the dose of levothyroxine had to be doubled and quadrupled respectively.