Introduction

Hashimoto’s thyroiditis (HT) is a chronic autoimmune disease that occurs in all age groups and presents in women to men 7:1.¹ It is characterized by lymphocytic infiltration of the thyroid gland, which usually results in impaired thyroid function and a painless goiter. The exact cause is unknown; however, certain factors can predispose individuals to the development of HT. These factors include genetic susceptibility, such as family history of autoimmune diseases, gene polymorphisms associated with autoimmune diseases (HLA-DR3, HLA-DR4, HLA-DR5, VDR etc.), and chromosomal abnormalities; environmental risk factors, such as selenium deficiency, pollutants, bacterial or viral infections (like EBV), pregnancy, stress; and various immunological factors are thought to play an important role. Thyroid function can be measured using several laboratory markers such as TSH, free T4, or free T3, while HT typically presents with elevated levels of TPOAb (90-95% of patients), TGAb (60-80% of patients), or TSH receptor blocking antibodies (10% of patients).¹

The Moderna mRNA vaccine enters the cell cytoplasm and is translated by the ribosomes to form perfusion-stabilized SARS-CoV-2 spike proteins. The spike proteins are transported to the cell surface and presented to the immune system. Some of the spike proteins are also processed into smaller peptides that are presented to the immune system. The spike protein peptides are presented to T cells via MHCII, while the spike proteins are presented to B cells via BCR.²

The severity of HT independently involves CD8+ activated T lymphocytes and thyroid auto-antibodies. IFN gamma, an inflammatory cytokine produced by Th1 cells, activates cytotoxic T lymphocytes and increases cell-mediated cytotoxicity. IFN gamma may therefore be one influencing factor in the severity of HT. Part of the mechanism of action of mRNA vaccines such as the Moderna COVID-19 vaccine is triggering of the IFN pathway. Theoretically, upregulation of the IFN pathway via mRNA vaccination in an already upregulated state could increase the severity of HT.^{3, 4}

Patient Information

Patient X is a 53-year-old Caucasian female with a history of Hashimoto’s thyroiditis, facial paralysis, flank pain, chronic fatigue, leg pain, chronic UTI’s, chronic constipation, and obesity who presented to BUC clinic for naturopathic evaluation and management of symptoms as well as improved quality of life.

Context: Symptoms of hypothyroidism appeared about 6 years ago including fatigue and cold intolerance. Patient was first seen at BUC in 2019 to improve thyroid function and improve overall health. Over the next several months, lifestyle, dietary intervention, and supplementation yielded an improvement in her hypothyroid symptoms; however, her physical and mental health began to decline during the COVID-19 pandemic. She received the Moderna COVID-19 mRNA vaccine in hopes of improving her immunity to COVID-19; however, facial paralysis and a worsening of symptoms began shortly thereafter.

Clinical Findings

Timeline

Diagnostic Assessment

Therapeutic Intervention

Discussion

This case showcases the importance of critical thinking, adaptability, and properly evaluating the risks and rewards of interventions such as vaccination in patients suffering from HT. Some of the strengths of this case were the lab testing done on the patient throughout the later stages of her symptomatology, as well as numerous doctor patient encounters over the past several years, during which her symptoms could be tracked. Specifically, the hyperactivity of her immune system, autoimmunity, and inflammation were key players in the reaction (facial paralysis) to the vaccine.

This is a relatively uncommon side effect with VAERS (Vaccine Adverse Event Reporting System) reporting 1986 cases of facial paralysis and 2681 cases of Bell’s palsy due to a COVID-19 vaccination (as of 8/12/21).^11,12 However, this potential side effect should be taken into consideration as patients’ quality of life can be significantly affected. Additionally, facial paralysis is only one of many potential adverse sequelae that can occur. A proposed mechanism for this outcome is the immunologic response from the vaccine triggers pre-existing underlying dysregulated immunological and inflammatory pathways. The patient’s lab work supports this hypothesis as her anti TPO antibodies increased exponentially from before and after the vaccination with no other major life events, diagnoses, or stressors occurring during that time. The patient’s inflammatory response was elevated pre-vaccine, but we don’t have data post-vaccine which is a limitation to this case study. However, it is suspected that her inflammatory status would be more elevated post-vaccine, especially given the exacerbation of her thyroid-related symptoms.

Currently, the Moderna vaccine has a 94.1% efficacy in preventing symptomatic, laboratory-confirmed COVID-19 among persons without evidence of previous SARS-CoV-2 infection in a study of over 30,000 people.¹³ Therefore, the risks and rewards of vaccination need to be critically evaluated in patients with HT and potentially other autoimmune conditions, as well as the efficacy of giving a second dose of the vaccine if the first dose yielded a negative reaction.^14-20

At this time, the patient’s prognosis is guarded, given the severity of symptoms and the patient’s various comorbidities. The future plan includes ordering follow up labs (listed in the diagnostic section), improving hypothyroid status with med management, dietary and lifestyle intervention, as well as reducing systemic inflammation with dietary, lifestyle, and supplement recommendations, and finally improving facial paralysis by treating underlying causes i.e. inflammation, immune dysregulation.

References

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