SARS-CoV-2-Related Subacute Thyroiditis, Myocarditis, and Hepatitis After Full Resolution of COVID-19 Serum Markers

Patient: Male, 64-year-old Final Diagnosis: Hepatitis • myocarditis • subacute thyroiditis Symptoms: Chest pain • sweating • tachycardia • tremor Medication: — Clinical Procedure: Cardiac enzymes • chemistry panels • complete blood count • echocardiography • electrocardiogram • gammagraphy • hepatic function tests • SARS-CoV-2 IgG antibodies • SARS-CoV-2 RT-PCR • thyroid function tests • thyroid ultrasonography Specialty: Cardiology • Endocrinology and metabolic OBJECTIVE: Unusual clinical course BACKGROUND: Subacute thyroiditis, myocarditis, and hepatitis are inflammatory disorders that may develop after viral infections, including SARS-CoV-2. These entities may appear after resolution of the respiratory syndrome. CASE REPORT: A previously healthy 64-year-old male patient came to the hospital reporting severe chest pain. He had a history of a COVID-19 pneumonia with PCR confirmation 4 weeks before. On admission to the Coronary Care Unit (CCU), the patient had a negative PCR for SARS-CoV-2; the following tests were performed: total T3 643.4 ng/dl (reference 35–193 ng/dl), total thyroxine 12.0 μg/dl (reference 4.8–11.7 μg/dl), free T4 1.85 ng/dl (reference 0.7–1.48 ng/dl), TSH 0.01 μIU/ml (reference 0.35–4.94 μIU/ml); total bilirubin 0.76 mg/dl (reference 0.0–1.5 mg/dl), alkaline phosphatase 185 U/L (reference 40–150 U/L), alanine aminotransferase 194.6 U/L (reference 6–66 U/L), aspartate aminotransferase 93.4 U/L (reference 9–55 U/L); on admission to the CCU high-sensitivity troponin I 548.3 pg/ml (reference 0.0–34.2 pg/ml), after 24 h in the CCU 801 pg/ml, and after 11 days (as an outpatient) 4.5 pg/ml. A thyroid gammagram revealed absent uptake of the radionuclide. Normal cardiac gammagraphy and cardiac enzymes ruled out myocardial ischemia and infarction. The following diagnoses were made: myocarditis, subacute thyroiditis, and reactive hepatitis due to SARS-CoV-2 infection. CONCLUSIONS: COVID-19 has been demonstrated to be a multisystemic inflammatory disorder. The serious illness that developed in our patient after relief of his pulmonary disease underlines this nature. We suggest close follow-up of patients even after apparent clinical resolution, and performing thyroid, myocardial, and liver tests if clinically indicated.