Graves Disease in the COVID-19 Era: Incidence Signals, Diagnostic Pitfalls and Practical Lessons for Clinicians

Background: Since early 2020, clinicians have reported Graves Disease (GD) diagnoses temporally linked to SARS-CoV-2 infection and vaccination, raising questions about true changes in GD incidence versus shifts in recognition, testing and referral. Objective: To synthesize peer-reviewed evidence on GD recognition and incidence during and after the COVID-19 pandemic, disentangling infection-related signals from vaccine safety data and summarizing implications for diagnosis and management. Methods: Narrative review of PubMed/MEDLINE and Google Scholar through September 20, 2025, including population‑based studies, center‑based cohorts, systematic reviews and mechanistic reports; reference lists were hand‑searched. Emphasis was placed on study design, confounding and risk windows. Results: Multiple pediatric and some adult center‑based cohorts reported higher rates of new GD diagnoses during the pandemic, with more symptomatic or biochemically severe presentations at diagnosis in youth. By contrast, large population‑based analyses have not detected an increased incidence of post‑vaccination GD or hyperthyroidism. Case reports and small series describe GD occurring after SARS‑CoV‑2 infection or vaccination; these clarify clinical phenotypes but cannot estimate risk. Mechanistic studies demonstrate ACE2 expression in thyrocytes and SARS‑CoV‑2 material in thyroid tissue, supporting plausibility for infection‑related thyroid autoimmunity. Conclusion: Evidence supports pandemic‑era increases in recognized GD in several cohorts, especially the pediatric ones susceptible to ascertainment and referral bias. Population‑level data do not implicate COVID‑19 vaccination in increasing incident GD. Clinicians should maintain a broad differential for post‑COVID hyperthyroidism, confirm GD with TRAb when possible and continue guideline‑concordant management while reassuring patients regarding vaccine safety.