Thyroid and adrenal glands at the time of SARS-CoV-2

Thyroid and adrenal glands at the time of SARS-CoV-2 and vaccines: 15+1 questions and answers

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Infection with the SARS-CoV-2 coronavirus has for some months now reached pandemic proportions, according to the World Health Organization, causing millions more deaths worldwide. This pandemic has undoubtedly affected the lives of all of us and is accompanied by a plethora of direct and indirect consequences. One of the consequences of this rapidly changing situation is the focus of efforts and attention of health workers and patients on the acute problem of infection that may in some cases lead to neglect of some chronic, also important health issues. 

Diseases of the thyroid gland are very common, usually chronic conditions. They have a wide range of pathogenesis and a variety of manifestations. Some of them are accompanied by hypo- or hyper-function of the gland (hypothyroidism, hyperthyroidism, thyroiditis, Hashimoto's, Graves'), while others require investigation, monitoring and treatment for the possibility of malignancy (thyroid nodules). 

On the other hand, adrenal diseases, although clearly less common, can be more serious. In particular, adrenal insufficiency (most commonly Addison's disease) can present serious complications with any infection, including that of SARS-CoV-2. 

As the vaccination programs of the population against the SARS-CoV-2 coronavirus have already begun, a plethora of questions have arisen around the triptych "thyroid-coronavirus-vaccine diseases". In this text, we set out in the form of questions and answers the data available so far regarding this triptych.

Thyroid diseases

Question 1. I suffer from autoimmune thyroid disease (Hashimoto's thyroiditis, Graves' disease). Does this mean that I am immunocompromised?

No. The pathways of the immune system responsible for fighting viral infections, including the SARS-CoV-2 coronavirus, appear to be different and independent of this part involved in autoimmune thyroid diseases. So far, there is no evidence that patients with autoimmune thyroid disease have a higher risk of getting the virus.

Question 2. Does my thyroid not be well regulated, does this increase the risk of contracting the SARS-CoV-2 coronavirus or the severity of symptoms?

The data so far are not entirely clear whether people with "poorly controlled" thyroid disease (usually patients who have started treatment very recently or are not receiving thyroid treatment as they should) are at greater risk of infection with the virus than in the general population. However, it seems very likely that these people, if they get sick, may be at greater risk of complications from the infection. 

This risk is most pronounced in cases of poorly regulated hyperthyroidism (or thyrotoxicosis or Graves' disease), particularly in older people. It is documented that poorly regulated hyperthyroidism is associated with increased cardiovascular mortality. Any infection in these patients, including that from the SARS-CoV-2 coronavirus, can trigger a number of very serious cardiovascular complications, such as arrhythmias and cardiac congestion. It is therefore very important that these patients have normal thyroid function as soon as possible. 

In conclusion, it is recommended that sufferers of thyroid diseases:

• Consult their endocrinologist 
• Continue to systematically receive their treatment to reduce potential risks

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Question 3. I am being treated with thyroxine. Does thyroxine increase the risk of contracting the SARS-CoV-2 coronavirus?

Clearly not. Levothyroxine, in whatever form it is taken, is not an immunomodulatory drug, that is, it does not affect or weaken the immune system. 

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Question 4. I am being treated for hyperthyroidism (carbimazole, methimazole, propylthiuracil). Do these drugs increase the risk of contracting the SARS-CoV-2 coronavirus?

No. Nor are these drugs immunomodulatory. In fact, they are valuable tools in the period of the SARS-CoV-2 coronavirus, as they help us regulate in a non-invasive way hyperthyroidism, which, if left unregulated, probably increases the risk of complications from the virus. It is therefore important that the patient complies with the treatment with these drugs in close cooperation with the attending endocrinologist. 

However, a rare side effect of these drugs is agranulocytosis (a condition that occurs in 0.2-0.5% of treated patients), in which the number of immune cells that fight infections is significantly reduced. This condition is manifested by symptoms, such as ulcers (thrushes) in the mouth or fever or sore throat. The difficulty lies in the fact that these symptoms are also symptoms of SARS-CoV-2 coronavirus infection. It is extremely difficult to distinguish clinically whether these symptoms are manifestations of agranulocytosis or the virus. Since agranulocytosis with fever can be a serious complication, the likelihood of its occurrence should not be overlooked. In these cases, the patient should immediately contact the attending endocrinologist in order to determine the optimal way of evaluation and treatment. The usual approach involves stopping treatment until the diagnosis is established and direct control of white blood cells (blood test for complete blood count).

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Question 5. Can the SARS-CoV-2 coronavirus cause thyroid disease?

Our knowledge of the various manifestations of the new virus, although incomplete, has certainly been enriched in recent months. Eight articles (case reports) in recent months have described cases of patients who previously did not suffer from a thyroid disease, who developed subacute thyroiditis after being diagnosed with COVID-19. Subacute thyroiditis is a disease of thyroid, viral or post-viral origin and is also called "De Quervain's", "granulomatous thyroiditis" or "thyroiditis of giant cells". The patient with subacute thyroiditis usually has fever, malaise, easy fatigue, myalgias and mainly pain in the cervix bilaterally or even contralaterally, often with a reflection of pain in the lower jaw and ear. The diagnosis is confirmed by the endocrinologist taking into account the clinical, hematological and radiological findings. Treatment in most cases involves the administration of cortisone.

Question 6. I am being treated with cortisone by my endocrinologist for thyroid-related diseases (most commonly subacute thyroiditis or thyroid eye disease). What do I need to know?

Cortisone, especially in high doses, is an immunosuppressive drug. Therefore, people treated with cortisone belong to the high-risk groups for viral infections. This risk generally increases depending on the duration and dose of treatment. On the other hand, the underlying thyroid diseases for which cortisone is administered are equally serious, so it is necessary to immediately bring them under control. The patient treated with cortisone should never interrupt his treatment, except after careful consultation with his attending endocrinologist. 

Question 7. I am pregnant and suffer from hypo- or hyper-thyroidism (either pre-existing pregnancy diagnosis or new diagnosis during pregnancy). What do I need to know?

Thyroid diseases should be perfectly regulated in pregnancy. Numerous studies have shown that poorly regulated hypothyroidism or hyperthyroidism is associated with complications of pregnancy or congenital abnormalities in the fetus, especially when the mother's disease is of autoimmune etiology. On the other hand, the pleasant thing is that thyroid diseases can be optimally regulated in pregnancy with the appropriate adaptation of medications, therefore all unpleasant consequences can be prevented.

Τα διαγνωστικά κριτήρια και η προσέγγιση των γυναικών με προβλήματα του θυρεοειδή κατά τη διάρκεια της κύησης είναι διαφορετικά από την αντίστοιχη προσέγγιση πριν και μετά την εγκυμοσύνη. Σε ό,τι αφορά τον υποθυρεοειδισμό, οι στόχοι της θεραπείας με θυροξίνη είναι πιο «αυστηροί» στη διάρκεια της εγκυμοσύνης, επιδιώκοντας τη διατήρηση των επιπέδων της θυρεοειδοτρόπου ορμόνης (TSH) <2.5 mIU/L ή <3 mIU/L, ανάλογα με το τρίμηνο της κύησης. 

As far as hyperthyroidism is concerned, in many cases the disease enters remission during pregnancy. But in several cases, treatment with antithyroid drugs is required. The recommendations of the endocrinology societies of Europe and America are for the administration of propylthiuracil during the first 16 weeks of pregnancy and, subsequently, if the patient still needs treatment, its replacement with methimazole. 

Another parameter of the approach of the pregnant woman with thyroid problems to pregnancy is the assessment of the risk of developing problems with the thyroid of the fetus or newborn. This risk can now be assessed very precisely by calculating the appropriate antibodies (TSH receptor antibodies). In any case, the monitoring of thyroid problems in a pregnant woman should be close, with regular communication with the endocrinologist. 

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Question 8. I suffer from thyroid disease and I have found that in recent months, during the containment measures due to the SARS-CoV-2 coronavirus pandemic, my mental health has deteriorated. What can I do?

The unprecedented conditions that all of us have been living in the last 12 months or so with the SARS-CoV-2 coronavirus pandemic have led to the deterioration of the mental health of a large part of the population. A recent study by the British Thyroid Foundation in the UK has emphatically confirmed this finding for patients with thyroid issues as well. The research of the medical team of M. Pavlatos, J. Priestley, C. McMullan and P. Perros on behalf of the British Thyroid Foundation included 633 patients, mostly women, with both hypo- and hyper-thyroidism. 58% of respondents felt that anxiety and depression increased during the pandemic. It is characteristic that the average score of the respondents regarding their quality of life before the pandemic was 7/10. That dropped to 5.6/10 during the pandemic.

Another important finding of the same research was that patients during this time felt that they had limited access to medical care in terms of thyroid issues. This is very likely to exacerbate the symptoms of anxiety and depression. 83% of the sample would welcome a program in which patients could potentially have telephone or video sessions with endocrinologists. Proper regulation of thyroid diseases can reduce the underlying stress during the pandemic and containment measures. Therefore, it is important for patients to maintain contact with their endocrinologist and even if they are hesitant to visit him in his clinic or clinic due to the risk of the SARS-CoV-2 coronavirus, to organize a telephone or video session using technology, if of course this is deemed appropriate by the doctor.

Thyroid nodules

Question 9. I have a nodule of the thyroid gland, which needs further investigation by puncture (biopsy or FNA- Fine Needle Aspiration). Is it safe to delay the biopsy of thyroid nodule?

Fortunately, most thyroid nodules are benign. However, some of them - and especially the older ones with suspicious features on ultrasound - are recommended to undergo a biopsy with a thin needle. Also, when the thyroid nodule is malignant (cancer), in most cases its progression is slow. Nevertheless, there are specific types or sub-types of thyroid cancer with more aggressive behavior, where early intervention can prevent the spread of the disease. The decision to perform a thyroid nodule biopsy is purely individualized, depending on the characteristics of each case and is taken by the endocrinologist in collaboration with the patient. 

Question 10. I have been diagnosed with thyroid cancer after a biopsy of nodule or nodules. Is it safe to delay surgery to treat thyroid cancer due to the coronavirus pandemic?

Surgical treatment is the primary and most basic means of treating thyroid cancer, in the vast majority of cases. Surgery includes total thyroidectomy and lymph node cleansing of the cervical compartments, when indicated. Due to the SARS-CoV-2 coronavirus pandemic, initially many scheduled surgeries were postponed, which creates understandable anxiety and concern about the timely treatment of malignancy.

It is, fortunately, comforting that most thyroid cancers are slowly evolving tumors with slow dispersal. However, there are exceptions, such as aggressive forms of papillary or follicular carcinoma, with infiltration of other structures of the cervix, but also the rarest carcinomas, anaplastic and myeloid. Finally, in some cases, patients experience difficulties breathing or swallowing due to an increase in the size of the nodule. 

In general, early surgical treatment of thyroid cancer is of key importance. It should also be emphasized that surgeries for the treatment of malignancy are also performed during the pandemic. It is therefore suggested that the patient with possible thyroid malignancy discusses thoroughly his diagnosis with the attending endocrinologist and endocrine surgeon for the safe planning of the surgery.

Thyroid cancer 

Question 11. In the past, I underwent thyroid surgery for cancer and/or received treatment with radioactive iodine. Am I at higher risk of contracting the SARS-CoV-2 coronavirus?

All the data we have so far suggest that there is no evidence that patients who were previously treated with radioactive iodine or underwent thyroid surgery are at increased risk of viral infection, as long as there is no evidence of residual malignancy or resurgence of the disease. It is, however, important for the patient to continue his monitoring normally with the attending endocrinologist, both in terms of substitution treatment with thyroxine (in order to avoid deregulation of the thyroid that increases the risk of viral infections), and in terms of general monitoring after treatment for malignancy that includes clinical evaluation, ultrasound control and in some cases the measurement of specific markers (thyroglobulin or calcitonin).

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Question 12. I recently underwent thyroid surgery or treatment with radioactive iodine. What should I do? 

If you have recently undergone treatment with radioactive iodine or thyroid surgery, you will need to start treatment with thyroxine. The dose of thyroxine is adjusted according to thyroid stimulating hormone (TSH) levels. The desired postoperative levels of TSH differ depending on the diagnosis (substitution treatment or sedation treatment), so you should discuss with your attending endocrinologist about the dose and proper reception of thyroxine, as well as the correct planning of repeat blood tests. 

Question 13. Due to my previous diagnosis with thyroid cancer, I am being treated with thyroxine at a dose of sedation, keeping thyroid stimulating hormone (TSH) low. Should I change anything because of the risk of infection with the SARS-CoV-2 coronavirus?

No. It is important to continue your treatment with thyroxine, with the same targets in terms of TSH levels, to reduce the risk of relapse. The dose of thyroxine will be adjusted if necessary by your endocrinologist depending on TSH levels.

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Question 14. I have been diagnosed with thyroid cancer and have received chemotherapy or kinase inhibitors or external radiation. What do I need to know about the risk of contracting the SARS-CoV-2 coronavirus I run? 

A small percentage of patients with thyroid cancer need more intensive treatment, in addition to thyroid/cervical surgery and radioactive iodine. Patients receiving chemotherapy or kinase inhibitors or who have received external radiation are high-risk groups for serious illness from the SARS-CoV-2 coronavirus and for this reason they should follow the instructions of EODY and contact their attending physician for further instructions. 

Question 15. I have thyroid disease. Is it safe to get vaccinated for the SARS-CoV-2 coronavirus?

The vaccination program of the general population against the coronavirus SARS-CoV-2 was recently launched in our country. With the data so far, three vaccines have been approved by the European Medicines Agency, while others are under approval. Clinical trials of the vaccines included tens of thousands of people. Since thyroid diseases are quite common and their existence was not a criterion for exclusion from vaccination during the clinical trials, it is considered certain that many thousands of people with thyroid diseases participated in the clinical trials. With the data so far, there are no reports of a higher risk of immediate or medium-term side effects from the vaccine in people with thyroid disease. Therefore, and as we wait for the publication of the detailed results of the clinical trials of the vaccines in patients with thyroid diseases, there does not appear to be a higher risk for people with thyroid diseases. Therefore, international scientific societies recommend vaccinating these people in parallel with the general population. Special sub-cases may be patients undergoing chemotherapy or treatment with kinase inhibitors or external irradiation for thyroid cancer or having a scheduled thyroid surgery very close to their vaccination date. In these cases, it is suggested to discuss the parameters in detail with the attending physician, with the aim of making the safest decision. 

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Adrenal glands

Question 16. I suffer from adrenal insufficiency and am treated with cortisone. Am I at higher risk of sars-CoV-2 coronavirus infection?

Adrenal insufficiency (as well as pituitary insufficiency) is a chronic condition characterized by a lack of cortisol production. As cortisol (steroid hormone) is absolutely essential for life, cortisone replacement therapy by these patients throughout their lifetime, in order to mimic normal plasma concentrations of cortisol, is a vital treatment.

Based on current data, it is not clear that patients with adrenal or pituitary insufficiency are at increased risk of contracting the SARS-CoV-2 coronavirus. However, we know that patients with Addison's disease (primary adrenal insufficiency) and congenital adrenal hyperplasia have a slightly increased overall risk of disease from infections. We also know that in cases of infection or any stress of the body (for example, bleeding, major surgery, etc.), the need for steroids increases significantly.  In case of suspected infection with the SARS-CoV-2 coronavirus, a timely modification of the substitution treatment should be determined as directed by your endocrinologist.  In addition, patients are advised to have at their disposal a sufficient stock of the cortisone preparations they use.