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Subacute thyroiditis following COVID-19 infection
Tiroiditis subaguda tras infección por COVID-19
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However, the causal virus is usually not identified, given that it does not entail changes to the treatment. A genetic predisposition and an association with certain human leukocyte antigen (HLA) haplotypes of the major histocompatibility complex have been described.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This entity is more frequent in women between 30 and 50 years of age. Symptoms include neck pain, general malaise, and thyroid dysfunction; these symptoms can be mistaken for illnesses that involve pharyngeal inflammation.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first described in Wuhan, China, in December 2019 and rapidly spread all over the world.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Thyroid dysfunction caused by coronaviruses other than SARS-CoV-2 has been described in patients without a prior history of thyroid disease.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">On June 9, 2020, a 36-year-old woman without any medical history of interest came to our clinic reporting anterior neck pain that radiated to the jaw that had been ongoing for two weeks. She also reported low-grade fever, palpitations, and fatigue. She did not present with tremor or ocular symptoms of thyrotoxicosis. A physical examination revealed that the thyroid gland was not increased in size and was sensitive to palpation as well as no adenopathy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">During the second week of April, the patient had presented with fever and head, neck, and muscle pain. These symptoms were compatible with SARS-CoV-2 infection. Her husband, a primary care physician whom she lives with, had been diagnosed with COVID-19 a few days earlier. She did not have an oropharyngeal swab for SARS-CoV-2 taken due to the limited availability of tests at that time. One month later, a serological test confirmed the diagnosis (positive IgG, negative IgM) through an immunochromatographic assay for the qualitative measurement of IgG and IgM.</p><p id="par0030" class="elsevierStylePara elsevierViewall">On a blood test from June, free thyroxine (FT4) was elevated with thyrotropin (TSH) suppression. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were high and leukocyte levels were normal. Thyrotropin receptor antibodies (TRAb), thyroglobulin antibodies (TGAb), and thyroid peroxidase antibodies (TPOAb) were measured and all were negative. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the laboratory test results.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In regard to imaging tests, both the thyroid ultrasound and gammagraphy were compatible with the suspected subacute thyroiditis. As initial treatment, she used a nonsteroidal anti-inflammatory drug (NSAID) (ibuprofen 600 mg), a beta blocker (propranolol 10 mg), and a stomach protector (omeprazole 20 mg). The doses of the drugs were reduced according to clinical and analytical progress. After 15 days, the inflammatory parameters had significantly decreased, with normal levels of free T4 and suppressed TSH. The patient did not report any symptoms.</p><p id="par0040" class="elsevierStylePara elsevierViewall">At the beginning of July, the patient’s blood test results were compatible with hypothyroidism; she did not have any symptoms. The dose of ibuprofen was again decreased; the stomach protector was maintained. Levothyroxine was not prescribed given that she was asymptomatic. In a later follow-up appointment in September, thyroid function and the inflammatory parameters had normalized and, finally, treatment was suspended.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Cases of subacute thyroiditis following SARS-CoV-2 infection have been reported in other countries: Italy (Brancatella et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Ippolito et al.,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Ruggeri et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>), Turkey (Asfuroglu et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>), the United States of America (Chong et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>), Mexico (Campos-Barrera et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>), and Singapore (Mattar et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>). The onset of this pathology, related to a viral infection or a postviral inflammatory reaction in subjects with a genetic predisposition, tends to occur two to eight weeks after said infection.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">It has been demonstrated that the thyroid gland contains a significant amount of angiotensin-converting enzyme 2 (ACE2), which is essential for SARS-CoV-2 to be able to invade human cells. This could be a plausible mechanism for the physiopathology of thyroiditis in COVID-19.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Similar cases have recently been published<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–13</span></a> that allow for considering SARS-CoV-2 as the probable viral trigger of our specific case.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Subacute thyroiditis is a self-limiting autoinflammatory disease characterized by a change in the thyroid follicles with inflammatory infiltration of giant cells, lymphocytes, and neutrophils.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Its incidence is 12.1 cases per 100,000 people per year and it is more frequent among women. The reported cases of thyroiditis following SARS-CoV-2 infection are all in women between 18 and 69 years of age.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–13</span></a> The patients reported neck pain, mild fever, and constitutional symptoms. In the described cases, including ours, symptoms started from one to six weeks after infection. Only two cases occurred at the same time.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Thyroid dysfunction in this disease is characterized by three phases: thyrotoxicosis, hypothyroidism, and euthyroidism.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> During the initial phase of follicle destruction, thyroid hormones are released into the blood, which is accompanied by the typical symptoms of hyperthyroidism (palpitations, weight loss, fatigue, etc.) and characteristic laboratory findings (ESR and CRP elevation, T3 not disproportionally elevated, and thyroid autoimmunity (TPO and antithyroglobulin) that is undetectable or present in low titers).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The thyroid ultrasound is characterized by diffuse bilateral hypoechoic areas and low or absent vascularization on a color Doppler ultrasound. The thyroid gammagraphy showed a block or decrease in uptake of the radiotracer.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Several weeks after the onset of symptoms, the thyroid hormone reserve is exhausted and the hypothyroid phase sets in, which will be permanent in a small percentage of cases.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,9</span></a> A return to a state of euthyroidism can take from one to six months.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Accepted treatment for this entity includes NSAIDs or steroids. Patients with palpitations, tremors, or jitteriness improve with beta blockers.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Thioamides must not be used.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Unlike the majority of reported cases, we treated our patient with an NSAID and propranolol; symptoms remitted after two weeks of treatment. Similarly, Chong et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> used acetylsalicylic acid and propranolol.</p><p id="par0080" class="elsevierStylePara elsevierViewall">We still have a lot to learn about the clinical manifestations of SARS-CoV-2 infection. We believe possible thyroid involvement must be taken into account given that it can go unnoticed in the face of the magnitude of this pandemic. Likewise, SARS-CoV-2 should be considered a possible causative agent of the thyroiditis cases we see in our clinical practice.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0085" class="elsevierStylePara elsevierViewall">This work has not received any type of funding.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: de la Higuera López-Frías M, Perdomo CM, Galofré JC. Tiroiditis subaguda tras infección por COVID-19. Rev Clin Esp. 2021;221:370–372.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">RR: reference range; TSH: thyroid stimulating hormone; T3: triiodothyronine; T4: thyroxine; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; TRAb: thyrotropin receptor antibodies; TGAb: thyroglobulin antibodies; TPOAb: thyroid peroxidase antibodies.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>Day 45 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>Day 58 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>Day 67 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>Day 151 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">06/10/2020 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">06/23/2020 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">07/02/2020 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">09/23/2020 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TSH [RR: 0.3–4.2 µU/mL] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.57 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total T3 [1.3–3.1 nmol/L] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Free T4 [12–22 pmol/L] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CRP [0–0,55 mg/dL] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ESR [mm/h] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leukocytes [3,890–9,230/μL] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7970 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TRAb [0–0.55 IU/L] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TGAb [0–75 IU/mL] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TPOAb [0–25 IU/mL] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2615152.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Days following COVID-19 infection.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Laboratory findings: subacute thyroiditis following COVID-19 infection.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical characteristics of subacute thyroiditis classified according to human leukocyte antigen typing" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 0 | 2 |
| 2024 October | 43 | 0 | 43 |
| 2024 September | 31 | 2 | 33 |
| 2024 August | 32 | 0 | 32 |
| 2024 July | 24 | 4 | 28 |
| 2024 June | 24 | 2 | 26 |
| 2024 May | 30 | 1 | 31 |
| 2024 April | 38 | 2 | 40 |
| 2024 March | 17 | 3 | 20 |
| 2024 February | 14 | 0 | 14 |
| 2024 January | 14 | 0 | 14 |
| 2023 December | 26 | 0 | 26 |
| 2023 November | 21 | 0 | 21 |
| 2023 October | 36 | 0 | 36 |
| 2023 September | 26 | 0 | 26 |
| 2023 August | 25 | 0 | 25 |
| 2023 July | 24 | 1 | 25 |
| 2023 June | 25 | 2 | 27 |
| 2023 May | 24 | 3 | 27 |
| 2023 April | 16 | 0 | 16 |
| 2023 March | 27 | 4 | 31 |
| 2023 February | 15 | 0 | 15 |
| 2023 January | 19 | 1 | 20 |
| 2022 December | 26 | 1 | 27 |
| 2022 November | 22 | 0 | 22 |
| 2022 October | 37 | 6 | 43 |
| 2022 September | 17 | 2 | 19 |
| 2022 August | 26 | 4 | 30 |
| 2022 July | 32 | 7 | 39 |
| 2022 June | 24 | 4 | 28 |
| 2022 May | 23 | 3 | 26 |
| 2022 April | 44 | 7 | 51 |
| 2022 March | 38 | 2 | 40 |
| 2022 February | 32 | 8 | 40 |
| 2022 January | 27 | 4 | 31 |
| 2021 December | 19 | 1 | 20 |
| 2021 November | 19 | 4 | 23 |
| 2021 October | 20 | 5 | 25 |
| 2021 September | 17 | 2 | 19 |
| 2021 August | 17 | 5 | 22 |
| 2021 July | 11 | 5 | 16 |
| 2021 June | 22 | 0 | 22 |
| 2021 May | 80 | 23 | 103 |
| 2021 April | 86 | 23 | 109 |
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