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Rose SR, Wassner AJ, Wintergerst KA, Yayah-Jones NH, Hopkin RJ, Chuang J, Smith JR, Abell K, LaFranchi SH, Wintergerst KA, Yayah Jones NH, Hopkin RJ, Chuang J, Smith JR, Abell K, LaFranchi SH, Wintergerst KA, Bethin KE, Bruggeman B, Brodsky JL, Jelley DH, Marshall BA, Mastrandrea LD, Lynch JL, Laskosz L, Burke LW, Geleske TA, Holm IA, Introne WJ, Jones K, Lyons MJ, Monteil DC, Pritchard AB, Smith Trapane PL, Vergano SA, Weaver K, Alexander AA, C4unniff C, Null ME, Parisi MA, Ralson SJ, Scott J. Congenital Hypothyroidism: Screening and Management. Pediatrics 2023; 151:190311. [PMID: 36827523 DOI: 10.1542/peds.2022-060419] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Untreated congenital hypothyroidism (CH) leads to intellectual disabilities. Newborn screening (NBS) for CH should be performed in all infants. Prompt diagnosis by NBS leading to early and adequate treatment results in grossly normal neurocognitive outcomes in adulthood. However, NBS for hypothyroidism is not yet practiced in all countries globally. Seventy percent of neonates worldwide do not undergo NBS. The recommended initial treatment of CH is levothyroxine, 10 to 15 mcg/kg daily. The goals of treatment are to maintain consistent euthyroidism with normal thyroid-stimulating hormone and with free thyroxine in the upper half of the age-specific reference range during the first 3 years of life. Controversy remains regarding the detection of thyroid dysfunction and optimal management of special populations, including preterm or low-birth-weight infants and infants with transient or mild CH, trisomy 21, or central hypothyroidism. NBS alone is not sufficient to prevent adverse outcomes from CH in a pediatric population. In addition to NBS, the management of CH requires timely confirmation of the diagnosis, accurate interpretation of thyroid function testing, effective treatment, and consistent follow-up. Physicians need to consider hypothyroidism in the face of clinical symptoms, even if NBS thyroid test results are normal. When clinical symptoms and signs of hypothyroidism are present (such as large posterior fontanelle, large tongue, umbilical hernia, prolonged jaundice, constipation, lethargy, and/or hypothermia), measurement of serum thyroid-stimulating hormone and free thyroxine is indicated, regardless of NBS results.
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Affiliation(s)
| | - Ari J Wassner
- Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kupper A Wintergerst
- Departments of Pediatrics, Division of Endocrinology & Diabetes, Wendy Novak Diabetes Center, University of Louisville, School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | | | | | | | - Jessica R Smith
- Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katherine Abell
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Genetics and Genomic Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Stephen H LaFranchi
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Sciences University, Portland, Oregon
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Yao B, Yang C, Pan C, Li Y. Thyroid hormone resistance: Mechanisms and therapeutic development. Mol Cell Endocrinol 2022; 553:111679. [PMID: 35738449 DOI: 10.1016/j.mce.2022.111679] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/03/2021] [Accepted: 05/09/2022] [Indexed: 10/18/2022]
Abstract
As an essential primary hormone, thyroid hormone (TH) is indispensable for human growth, development and metabolism. Impairment of TH function in several aspects, including TH synthesis, activation, transportation and receptor-dependent transactivation, can eventually lead to thyroid hormone resistance syndrome (RTH). RTH is a rare syndrome that manifests as a reduced target cell response to TH signaling. The majority of RTH cases are related to thyroid hormone receptor β (TRβ) mutations, and only a few RTH cases are associated with thyroid hormone receptor α (TRα) mutations or other causes. Patients with RTH suffer from goiter, mental retardation, short stature and bradycardia or tachycardia. To date, approximately 170 mutated TRβ variants and more than 20 mutated TRα variants at the amino acid level have been reported in RTH patients. In addition to these mutated proteins, some TR isoforms can also reduce TH function by competing with primary TRs for TRE and RXR binding. Fortunately, different treatments for RTH have been explored with structure-activity relationship (SAR) studies and drug design, and among these treatments. With thyromimetic potency but biochemical properties that differ from those of primary TH (T3 and T4), these TH analogs can bypass specific defective transporters or reactive mutant TRs. However, these compounds must be carefully applied to avoid over activating TRα, which is associated with more severe heart impairment. The structural mechanisms of mutation-induced RTH in the TR ligand-binding domain are summarized in this review. Furthermore, strategies to overcome this resistance for therapeutic development are also discussed.
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Affiliation(s)
- Benqiang Yao
- The State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling Network, School of Life Sciences, Xiamen University, Fujian, 361005, China
| | - Chunyan Yang
- The State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling Network, School of Life Sciences, Xiamen University, Fujian, 361005, China.
| | - Chengxi Pan
- The State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling Network, School of Life Sciences, Xiamen University, Fujian, 361005, China
| | - Yong Li
- The State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling Network, School of Life Sciences, Xiamen University, Fujian, 361005, China.
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Rodriguez L, Dinauer C, Francis G. Treatment of hypothyroidism in infants, children and adolescents. Trends Endocrinol Metab 2022; 33:522-532. [PMID: 35537910 DOI: 10.1016/j.tem.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/11/2022] [Indexed: 11/22/2022]
Abstract
In 2014, treatment guidelines from the American Thyroid Association reflected the general consensus that levothyroxine (LT4), adjusted to maintain a normal thyrotropin (TSH) level, is the preferred method for treatment of hypothyroidism. Although this is generally applicable to children, there are subsets of children for whom the diagnosis and treatment of hypothyroidism are problematic. These include children with congenital hypothyroidism (CH), low birth weight (LBW) and very low birth weight (VLBW), Down syndrome (DS), subclinical hypothyroidism, and obesity. In this Review, we focus on the progress and remaining pitfalls in diagnosis and treatment of hypothyroidism in these and other groups.
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Affiliation(s)
- Luisa Rodriguez
- Assistant Professor of Pediatrics, Division of Endocrinology and Diabetes, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Catherine Dinauer
- Associate Professor of Pediatrics, Division of Endocrinology, Yale University, New Haven, CT, USA
| | - Gary Francis
- Professor of Pediatrics, Division of Endocrinology and Diabetes, University of Texas Health Science Center San Antonio, San Antonio, TX, USA.
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Neuropsychological Alterations in Patients with Congenital Hypothyroidism Treated with Levothyroxine: Linked Factors and Thyroid Hormone Hyposensitivity. J Clin Med 2022; 11:jcm11123427. [PMID: 35743497 PMCID: PMC9224966 DOI: 10.3390/jcm11123427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 12/04/2022] Open
Abstract
Eighty-five percent of the studies of patients with congenital hypothyroidism (CH) treated with Levothyroxine (L-T4) report neuropsychological sequelae throughout life. In neonates and infants, there is a deficit in sensorimotor skills (impaired balance). In preschool and elementary school children and adolescents, there are alterations in intellectual quotient (low scores), language (delayed phonological acquisition), memory (visual, verbal, visuospatial, visuoconstructive, autobiographical, and semantic), sensorimotor skills (impaired fine and gross motor control), and visuoconstructive–visuospatial domain (low scores in spatial location, block design, and object assembly). These neuropsychological domains are also affected in young adults, except for language (adequate verbal fluency) and visuoconstructive–visuospatial domain (no data). The onset and severity of neuropsychological sequelae in patients with treated CH depend on several factors: extrinsic, related to L-T4 treatment and social aspects, and intrinsic, such as severity and etiology of CH, as well as structural and physiological changes in the brain. In this review, we hypothesized that thyroid hormone hyposensitivity (THH) could also contribute to neuropsychological alterations by reducing the effectiveness of L-T4 treatment in the brain. Thus, further research could approach the THH hypothesis at basic and clinical levels to implement new endocrinological and neuropsychological therapies for CH patients.
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Clinical Thyrotoxicosis Resulting from Liothyronine Augmentation of Antidepressant Therapy in an Adolescent. Case Rep Psychiatry 2022; 2022:2270202. [PMID: 35656555 PMCID: PMC9155938 DOI: 10.1155/2022/2270202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/14/2022] [Indexed: 01/29/2023] Open
Abstract
Background/Objective. Thyrotoxicosis, a condition resulting from excessive peripheral thyroid hormone, is typically accompanied by thyroid function tests demonstrating a high free thyroxine (free T4) with appropriate suppression of thyroid-stimulating hormone (TSH). Case report. We describe a 17-year-old female presenting with symptoms of thyrotoxicosis along with suppressed TSH and low free T4, a laboratory pattern concerning for central hypothyroidism. Further history revealed that she was prescribed liothyronine as an adjunct therapy for depression. Discussion. Due to the short half-life of liothyronine, clinical signs and symptoms of thyrotoxicosis may develop before detection by interval lab monitoring. Conclusion. This case highlights the need for close monitoring and caution when treating adolescents with liothyronine and the importance of interpreting atypical laboratory findings within clinical context.
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Radetti G, Rigon F, Salvatoni A, Campi I, De Filippis T, Cirello V, Longhi S, Guizzardi F, Bonomi M, Persani L. Tissue sensitivity to thyroid hormones may change over time. Eur Thyroid J 2022; 11:e210054. [PMID: 35060923 PMCID: PMC9142803 DOI: 10.1530/etj-21-0054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/21/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Patients with congenital hypothyroidism (CH) may transiently show a certain degree of pituitary resistance to levothyroxine (LT4) which, however, normalizes subsequently. However, in some individuals, thyroid-stimulating hormone (TSH) fails to normalize despite adequate LT4 treatment. METHODS Nine patients with CH followed in three Academic Centre who developed over time resistance to thyroid hormones underwent extensive biochemical and genetic analyses. These latter were performed by Sanger sequence or targeted next-generation sequencing technique including a panel of candidate genes involved in thyroid hormone actions and congenital hypothyroidism (CH): THRA, THRB, DIO1, DIO2, SLC16A2, SECISBP2, DUOX2, DUOXA2, FOXE1, GLIS3, IYD, JAG1, NKX2-1, NKX2- 5, PAX8, SLC26A4, SLC5A5, TG, TPO, TSHR. RESULTS All patients displayed a normal sensitivity to thyroid hormone (TH) in the first years of life but developed variable degrees of resistance to LT4 treatment at later stages. In all cases, TSH normalized only in the presence of high free thyroxine levels. Tri-iodothyronine suppression test followed by thyrotrophin-releasing hormone stimulation was performed in two cases and was compatible with central resistance to THs. This biochemical feature was present independently on the cause of CH, being observed either in patients with an ectopic (n = 2) or eutopic gland (n = 3) or in case of athyreosis (n = 1). None of the patients had genetic variants in genes involved in the regulation of TH actions, while in two cases, we found two double heterozygous missense variants in TSHR and GLIS3 or in DUOX2 and SLC26A4 genes, respectively. CONCLUSIONS We report CH patients who showed an acquired and unexplainable pituitary refractoriness to TH action.
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Affiliation(s)
- Giorgio Radetti
- Marienklinik, Bolzano, Italy
- Correspondence should be addressed to G Radetti:
| | - Franco Rigon
- Department of Paediatrics, University of Padua, Padua, Italy
| | | | - Irene Campi
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Tiziana De Filippis
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Valentina Cirello
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Silvia Longhi
- Department of Paediatrics, Regional Hospital of Bolzano, Bolzano, Italy
| | - Fabiana Guizzardi
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Marco Bonomi
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luca Persani
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
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Bauer AJ, Wassner AJ. Thyroid hormone therapy in congenital hypothyroidism and pediatric hypothyroidism. Endocrine 2019; 66:51-62. [PMID: 31350727 DOI: 10.1007/s12020-019-02024-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/17/2019] [Indexed: 12/11/2022]
Abstract
The evaluation and management of hypothyroidism in children are similar to adults, but there are important differences based on the dependence on normal thyroid function for neurocognitive and physical development. In the pediatric population, hypothyroidism is frequently categorized as congenital or acquired hypothyroidism, depending on the age of presentation and the underlying etiology. The evaluation and management of children and adolescents with hypothyroidism are determined by the etiology as well as by the age at diagnosis, severity of the hypothyroidism, and the response to thyroid hormone replacement therapy. Children and adolescents require higher weight-based doses for thyroid hormone replacement than do adults, likely due to a shorter half-life of thyroxine (T4) and triiodothyronine (T3) in children, but weight-based dose requirements decrease as the child advances into adulthood. Multiple gaps in knowledge remains regarding how to optimize the treatment of hypothyroidism in pediatric patients, including (but not limited to) the selection of patients with subclinical hypothyroidism for treatment, and the potential benefit of combined LT3/LT4 therapy for patients with persistent symptoms and/or low T3 on LT4 monotherapy. The life-long impact on growth and development, and potentially on long-term cardiovascular and psychosocial health, are significant and highlight the importance of future prospective studies in pediatric patients to explore these areas of uncertainty.
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Affiliation(s)
- Andrew J Bauer
- The Thyroid Center, Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, The Perelman School of Medicine, The University of Pennsylvania, 3500 Civic Center Boulevard, Buerger Center, 12-149, Philadelphia, PA, 19104, USA.
| | - Ari J Wassner
- Thyroid Program, Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, 333 Longwood Avenue, 2nd floor, Boston, MA, 02115, USA
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