Graves' disease following immunosuppression withdrawal and SARS-CoV-2 infection in a failed kidney allograft recipient: a case report on immune reconstitution.

Immune recovery after withdrawal of long-term immunosuppression may unmask autoimmune disease, but thyroid autoimmunity in patients with failed kidney allografts remains poorly characterized. We report a 29-year-old man with kidney allograft failure who developed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection after discontinuation of maintenance immunosuppression and subsequently presented with weight loss, tremor, tachycardia, diffuse goiter, and overt thyrotoxicosis. Positive thyrotropin receptor antibodies (TRAb) and diffusely increased radionuclide uptake supported a diagnosis of Graves' disease rather than destructive thyroiditis. His symptoms and thyroid function improved following treatment with methimazole, propranolol, glucocorticoids, and supportive treatment. Extracorporeal blood-purification therapies were used in the setting of persistent tachycardia, dialysis-related blood pressure fluctuations, and systemic inflammation, although their independent contribution could not be determined. Persistently elevated TRAb levels despite low peripheral B-cell counts suggested that circulating B-cell numbers did not reliably reflect humoral autoimmune activity. This case highlights a possible immune reconstitution-associated form of thyroid autoimmunity after immunosuppression withdrawal and emphasizes early recognition and thyroid evaluation following new inflammatory triggers.