Natural course of juvenile autoimmune thyroiditis

New and old criteria for diagnosing celiac disease: do they really differ? A retrospective observational study

BACKGROUND

The aim of this study is to compare two groups of celiac patients: the first one, in which diagnosis was based on a "biopsy sparing" approach according to the 2012 ESPGHAN criteria, and the second one, based on the biopsy approach like the one of the 1991 Revised Criteria, in order to find relevant difference for sex, M/F ratio, age at diagnosis, clinical features at the onset, presence and prevalence of concomitant autoimmune disorders.

METHODS

Our study involves 61 patients having the Celiac Disease (CD) onset from February 2013 to February 2020. The 32 patients who received diagnosis according "biopsy sparing" criteria were enrolled in group (1) The 29 patients who received diagnosis by duodenal biopsy were enrolled in group (2) Prevalence of comorbidities was analysed through chi-square test.

RESULTS

In group 1 the prevalence of comorbidities such as Insulin-Dependent Diabetes Mellitus (IDDM) and thyroiditis was of 53%, while in group 2 it was only of 24%. Analysing the IDDM prevalence between the two groups we found a relevant difference. At the same time, the prevalence of thyroiditis was also significantly different. In group 1, male patients, in particular, would seem to have a higher incidence of CD related autoimmune disorders.

CONCLUSIONS

An increased prevalence of IDDM, thyroiditis and juvenile idiopathic arthritis (JIA) in the first group would show that the "biopsy sparing" approach could expose patients to a greater length of disease activity that might be responsible for the onset of such comorbidities. Further studies should be carried out on more numerous samples of patients in order to confirm or not these data.

Improving iodine nutritional status and increasing prevalence of autoimmune thyroiditis in children

OBJECTIVE

The objective of this study is to evaluate the link between excess iodine intake as evidenced by increased urinary iodine excretion (UIE) and autoimmune thyroiditis in children and to assess the correlation between UIE and thyroid microsomal antibody (thyroid peroxidase [TPO]) titers in children.

MATERIALS AND METHODS

All children with goiter between age group 6 and 12 years, were subjected to blood tests for free thyroxine, thyroid stimulating hormone, and TPO antibody, fine needle aspiration was advised for all children with goiter. Forty-three children with confirmed autoimmune thyroiditis served as cases, and 43 children with euthyroid goiter with workup negative for autoimmune thyroiditis and iodine deficiency were enrolled as controls. UIE was estimated in spot urine sample for both cases and controls. The levels of urinary iodine were compared between cases and controls.

RESULTS

The levels of urinary iodine were significantly higher in children with autoimmune thyroiditis as compared with control. There was a positive correlation between UIE and antimicrosomal antibody titers among cases. Among cases 65% children had subclinical hypothyroidism, 27.9% had overt hypothyroidism and 7% of cases, and 100% of controls had euthyroid functional status. Excessive (≥300 μg/L) UIE was strongly associated with autoimmune thyroiditis. If the UIE level is ≥ 300 μg/L, then there is 17.94 times higher chance of having amiodarone-induced thyrotoxicosis than those who have UIE level < 300 μg/L (P < 0.001).

CONCLUSIONS

A possible association between increased iodine intake and autoimmune thyroiditis was found in this study. Excessive iodine intake may trigger thyroid autoimmunity and eventually thyroid hypofunction.

Five-Year Prospective Evaluation of Thyroid Function Test Evolution in Children with Hashimoto's Thyroiditis Presenting with Either Euthyroidism or Subclinical Hypothyroidism

BACKGROUND

Whether the course of thyroid function in Hashimoto's thyroiditis (HT) differs in children who present with either euthyroidism or subclinical hypothyroidism (SH) has been incompletely investigated.

AIM

Using a five-year prospective evaluation of 234 children with HT and no prognostic risk factors, this study investigated whether the evolution of the thyroid status is influenced by the biochemical pattern at initial diagnosis.

RESULTS

In the entire series, thyrotropin values significantly increased during follow-up, while free thyroxine values decreased and the proportion of children with a thyroid dysfunction increased from 27.3% to 47.4% (p = 0.0001). An increasing proportion of cases with severe thyroid dysfunction was identified, especially among the 64 patients presenting with SH (group B), but also among the 170 children presenting with euthyroidism (group A) at initial diagnosis. At the end of follow-up, the prevalence of children with overt hypothyroidism was 12.3% in group A compared with 31.2% in group B (p = 0.0007). In the overall population, however, the majority of patients (52.6%) exhibited biochemical euthyroidism at the end of follow-up.

CONCLUSIONS

Children with HT may develop a deterioration of thyroid status during the first five years of disease. Such a trend may be observed, even in the patients who initially present with a mild biochemical picture (either SH or euthyroidism). A total of 57.1% of initially euthyroid children remain euthyroid, and 40.6% of patients with initial SH normalize thyroid function within five years after HT diagnosis. The patients presenting with SH are more prone to the risk of developing severe thyroid dysfunction over time.

The role of the resistive index in Hashimoto's thyroiditis: a sonographic pilot study in children

OBJECTIVE

The role of Doppler ultrasonography in the diagnosis of diffuse thyroid diseases is not well established. In particular, Doppler ultrasonography findings in children with Hashimoto's thyroiditis are very limited. We examined gray-scale and Doppler ultrasound findings in Hashimoto's thyroiditis in children in an attempt to understand the feasibility of future prospective controlled studies.

MATERIALS AND METHODS

Twenty-one children with newly diagnosed Hashimoto's thyroiditis were recruited in the study. The patients were euthyroid or had subclinical hypothyroidism at the time of the ultrasonography examination. According to the color Doppler scale developed by Schulz et al., thyroid glands were classified into four patterns based on visual scoring and the mean resistive index (RI), which was calculated via measurements from both lobes, and these results were compared with gray-scale findings.

RESULTS

The mean RI value, calculated as the mean of the RI values of both lobes obtained from each patient, was found to be 0.57 ± 0.05 (range 0.48-0.67) cm/sn. The distribution of thyroid classifications was as follows: Pattern 0, n = 7; Pattern I, n = 6; Pattern II, n = 4; and Pattern III ("thyroid inferno"), n = 4. The mean RI values in patients with normal or near-normal gray-scale findings (n = 10) and patients with more substantial gray-scale changes (n = 11) were not significantly different and were lower than the values in normal children previously presented in the literature.

CONCLUSION

The results indicated that the RI may be more sensitive than other ultrasound parameters for the diagnosis of Hashimoto's thyroiditis.

Clinical course of Hashimoto's thyroiditis and effects of levothyroxine therapy on the clinical course of the disease in children and adolescents

OBJECTIVE

The aim of this study was to evaluate the clinical course of Hashimoto's thyroiditis (HT) in children and adolescents and the effects of levothyroxine therapy on the clinical course and laboratory findings.

METHODS

The clinical and laboratory data of 101 patients with HT at presentation and during a three-year follow-up period were retrospectively evaluated using patient records.

RESULTS

The mean age of the patients at the time of diagnosis was 12.3 ± 2.90 years and female/male ratio was 5.7/1. The complaint at the time of hospital presentation was goiter in 57.8% of the patients. At baseline, 36.7% of the patients were euthyroid, whereas 32.7% had subclinical hypothyroidism, 16.6 % of subjects were evaluated as hypothyroid. Twelve of the 28 patients who were initially euthyroid and not receiving therapy developed subclinical or overt hypothyroidism during the first 18 months of the follow-up period and were started on thyroid medication. At presentation, the mean anti-thyroglobulin (anti-Tg) and anti-thyroperoxidase antibody levels were 450 ± 725 IU/mL and 392 ± 428 IU/mL, respectively and at the end of the follow-up period, a significant decrease was observed in the anti-Tg levels of patients receiving levothyroxine from the beginning.

CONCLUSIONS

Thyroid functions of the patients with HT should be monitored periodically for hypothyroidism. Levothyroxine therapy may positively affect the clinical course of the disease and the antibody titers.

The frequency of Hashimoto thyroiditis in children and the relationship between urinary iodine level and Hashimoto thyroiditis

The aim of this study was to determine the frequency of thyroid autoimmunity in second grade primary school students and to examine the relationship between iodine and Hashimoto thyroiditis (HT). This was a cohort study performed with 1000 students. Urinary iodine levels, antithyroid peroxidase (anti-TPO) and antithyroglobulin (anti-Tg) antibodies were determined in all children. Children with anti-TPO or anti-Tg antibody positivity or with goiter were summoned for detailed examinations. In total, 36 cases (3.6%) were diagnosed as HT. The goiter frequency was found in 17.5% of the whole cohort. Additionally, iodine deficiency was found in 64.2% of all children. The median urinary iodine excretion was determined as 132 microg/L (range 382 microg/L) in the HT group, whereas it was 73 microg/L (range 390 microg/L) in children with goiter but without HT and 81 microg/L (range 394 microg/L) in normal children. The urinary iodine level of HT cases was significantly higher than the other two groups (p < 0.001). HT was also determined in 2% of patients with low urinary iodine levels, in 6.2% of patients with normal urinary iodine levels, and in 7.5% of patients with high urinary iodine levels. Our data demonstrates the close relationship between excessive iodine levels and autoimmunity.

A 5-year-old boy with atrophic autoimmune thyroiditis caused by thyroid-stimulation blocking antibodies

A 5-year-old boy was presented for a growth disturbance, which was initially noted at 3 years of age. Endocrinological testing identified severe hypothyroidism, defined by the following levels: TSH 990.5 microU/mL, F-T3 0.26 pg/mL, and F-T4 0.09 ng/dL. Serum anti-thyroid peroxidase (TPO) antibodies were 158 IU/mL and serum thyroid-stimulation blocking antibodies (TSBab) levels were 82.1 IU/mL (normal range < 45.6). Thyroid scintigraphy with 99mTc showed markedly decreased uptake, and magnetic resonance imaging (MRI) revealed pituitary hyperplasia. He was diagnosed with atrophic autoimmune thyroiditis. His thyroid function and pituitary size normalized following thyroid hormone replacement therapy. We report a rare case of a young boy with atrophic thyroiditis caused by TSBab.

Autoimmune thyroiditis in antinuclear antibody positive children without rheumatologic disease

BACKGROUND

Children are commonly referred to a pediatric rheumatology center for the laboratory finding of an Anti-nuclear antibody (ANA) of undetermined significance. Previous studies regarding adult rheumatology patients have supported an association between ANA and anti-thyroid antibodies, with the prevalence of thyroid antibodies being significantly higher in patients referred to a rheumatology center for an ANA without evidence of connective tissue disease compared to the general population. The purpose of the present study was to determine the frequency of thyroid antibodies in children referred to a pediatric rheumatology center for a positive ANA without evidence of a connective tissue disease.

METHODS

A retrospective chart review was performed on children who were referred to our pediatric rheumatology center between August 2003 and March 2007 for positive ANA with concurrent thyroid antibody and thyroid function tests performed who did not fulfill criteria for a specific connective tissue disease. Laboratory and clinical features were recorded and analyzed. Mean and standard deviation were used to describe continuous data. Chi-square or Fisher's exact tests were used to compare proportions between variables.

RESULTS

One-hundred and four ANA-positive patients with concurrent thyroid studies were evaluated (88% female, 93% Caucasian, mean age 11.9 +/- 4.0 years). Half of patients had an ANA titer >/= 1:320. The ANA pattern was speckled in 60% of the patients. Thyroid antibodies were detected in 30% of the patients. Anti-Thyroglobulin (ATG) was detected in 29% and Anti-thyroid peroxidase (ATPO) in 21% of the patients; of these children, 14% had hypothyroidism. ANA pattern and titer were not associated with anti-thyroid antibody positivity.

CONCLUSION

Thyroid antibodies associated with chronic lymphocytic thyroiditis, ATG and ATPO, were detected significantly higher in ANA-positive children without a rheumatologic condition (30%) as compared to the general pediatric population (1.3 - 3.4%). ANA titer and pattern did not help predict the presence or absence of thyroid antibodies. Given the high frequency of thyroid antibodies and increased risk of developing hypothyroidism over time, routine evaluation of ATG and ATPO with thyroid function tests in ANA-positive children is recommended.

Prevalence and functional significance of thyrotropin receptor blocking antibodies in children and adolescents with chronic lymphocytic thyroiditis

CONTEXT

TSH receptor (TSHR) blocking antibodies (Abs) inhibit TSH-induced thyroid growth and function in some adults with chronic lymphocytic thyroiditis (CLT), but their role in the pediatric age range is unknown.

OBJECTIVES

Our objectives were: 1) to determine the prevalence of TSHR blocking Abs in children and adolescents with CLT and 2) assess their functional significance both in vivo and in vitro.

DESIGN AND SETTING

This was a retrospective study in a referral outpatient setting.

PATIENTS

Sera from a total of 87 CLT patients and 33 controls were studied.

MAIN OUTCOME MEASURES

TSHR Abs were measured by both ELISA and bioassay.

RESULTS

Eight of 87 children and adolescents with CLT (9.2%), including one as young as 4 yr of age, had TSHR Abs in serum as measured by ELISA. The prevalence was significantly higher in individuals whose serum TSH concentration was 20 mU/liter or greater within 3 months of study than in less hypothyroid patients (eight of 45 vs. none of 42, P < 0.005). Conversely, TSHR Ab-positive patients were significantly more hypothyroid at diagnosis but only when the analysis was restricted to those with severe hypothyroidism was a decreased prevalence of goiter observed. IgG purified from TSHR Ab sera retained the TSH binding-inhibitory activity and TSHR Ab-positive sera inhibited TSH-induced stimulation of cAMP significantly more than normal.

CONCLUSIONS

TSHR-blocking Abs contribute significantly to the severity of the hypothyroidism in some children with CLT, but as compared with adults, they appear to play less of a role in determining the presence or absence of a goiter.

Assessment of thyroid function during the long course of Hashimoto's thyroiditis in children and adolescents

CONTEXT

The prognosis of Hashimoto's thyroiditis (HT) in children and adolescents is not well known and studies reporting long-term outcome of the disease are scarce.

OBJECTIVE

To assess the thyroid hormone status during long-term follow-up and to establish the prognosis of children and adolescents with HT.

PATIENTS

One hundred and twenty-nine patients with HT were re-evaluated for thyroid hormone status after a mean follow-up period of 50 months.

RESULTS

Seventy-seven per cent of the euthyroid patients were still euthyroid, while 21.1% of these patients became hypothyroid at the time of re-evaluation. However, 69.5% of hypothyroid patients remained hypothyroid (overt or subclinical) and 30.5% recovered.

CONCLUSION

HT is a dynamic process. Thyroid functions can show variation during follow-up. Therefore, thyroid function tests should be repeated periodically to detect progression to hypothyroidism in initially euthyroid patients as well as reversibility of hypothyroidism.

Natural history of thyroid function tests over 5 years in a large pediatric cohort

CONTEXT

Because clinical manifestations of thyroid disorders are variable and subtle in children and adolescents, thyroid function tests are often repeated in patients with nonspecific symptoms.

OBJECTIVES

The objective of the study was to determine the natural history of initial abnormal TSH and define populations at greater risk for developing a subsequent thyroid dysfunction.

METHODS

A total of 121,052 of 1.043 million outpatients aged 0.5-16 yr insured by the Clalit Health Medical Organization had a TSH determination in 2002 and follow-up to 2007. Extracted from the Clalit Health Medical Organization database were their demographic data, referral diagnoses, and laboratory results (TSH, free T(4), thyroid antibodies). Excluded were patients with overt hypothyroidism or hyperthyroidism on initial testing.

RESULTS

Results of 96.5% of initial serum TSH concentrations were normal (0.35-5.5 mIU/liter), 0.2% were low (<0.35 mIU/liter), 2.9% elevated (>5.5 to <or=10 mIU/liter), and 0.4% highly elevated (>10 mIU/liter). The frequency of TSH testing increased with age and female gender. During follow-up, repeated (two to more than four) TSH tests were performed in 45.7% of the patients. In the second TSH determination, normal TSH was documented in 40, 73.6, and 78.9% of those whose initial serum TSH was highly elevated, elevated, and low, respectively, and in 97% of those with normal initial TSH. Predictive factors for a sustained highly elevated TSH were initial TSH greater than 7.5 mIU/liter (P = 0.014) and female gender (P = 0.047).

CONCLUSIONS

In the pediatric population, initial normal or slightly elevated TSH levels are likely to remain normal or spontaneously normalize without treatment. Patients with initial levels greater than 7.5 mIU/liter, particularly girls, are at a greater risk for sustained abnormal TSH levels.

Goitrous autoimmune thyroiditis in a pediatric population: a longitudinal study

BACKGROUND

Patients with autoimmune thyroiditis can present with thyroid function that varies from euthyroidism to frank hypothyroidism or occasionally hyperthyroidism. Although there is a risk of progression from the euthyroid or subclinical hypothyroid state to frank hypothyroidism, the rate of progression is not known.

OBJECTIVES

Subjects with diffuse goiter and autoimmune thyroiditis were followed up to observe the rate of deterioration in thyroid function from euthyroid and subclinical hypothyroid states to hypothyroidism.

METHODS

Patients who presented with goiter and autoimmune thyroiditis were grouped as those with euthyroidism, subclinical hypothyroidism, and overt hypothyroidism on the basis of levels of thyroxine and thyrotropin at presentation. Patients were followed up for a minimum duration of 24 months with periodic monitoring of thyroid function.

RESULTS

Ninety-eight consecutive subjects (aged of 8-18 years) with a diagnosis of autoimmune thyroiditis and diffuse goiter were studied. At presentation, in 24 subjects (24.5%) thyroid function was normal (euthyroidism), 32 (32.6%) had subclinical hypothyroidism, and the remaining 42 subjects (42.9%) had hypothyroidism. All of the subjects with hypothyroid were maintained euthyroid on thyroxine during follow-up. Hypothyroidism developed in 3 of 24 patients with euthyroidism and in 4 of 32 patients with subclinical hypothyroidism.

CONCLUSIONS

Subjects with goitrous autoimmune thyroiditis need periodic monitoring of thyroid function. Development of thyroid dysfunction is insidious and may not be accompanied by symptoms and clinical signs. In pediatric and adolescent age groups it is imperative to correct thyroid dysfunction to achieve optimal growth and development.

Hashimoto's thyroiditis in children and adolescents: a retrospective study on clinical, epidemiological and laboratory properties of the disease

Hashimoto's thyroiditis (HT) is the most common cause of goiter and acquired hypothyroidism in children and adolescents in iodine replete areas. To find out the clinical, epidemiological and laboratory characteristics of the disease in childhood, we reviewed files of 162 children and adolescents with HT followed in the Department of Pediatric Endocrinology, Hacettepe University Faculty of Medicine.

RESULTS

Female patients constituted 86.4% (n = 140) of all patients with a female:male ratio of 6.4. Mean age at diagnosis was 11.4 +/- 2.97 years (age range 4.4-16.5 years). At the time of diagnosis 43.2% of the patients (n = 70) were euthyroid, 24.1% (n = 39) had subclinical hypothyroidism, 21% (n = 34) had overt hypothyroidism, and 8.6% (n = 14) had overt and 3.1% (n = 5) subclinical hyperthyroidism.

CONCLUSIONS

Autoimmune thyroiditis is more frequent in females, and increases in frequency over age during childhood and adolescence. At the time of diagnosis, frequency of overt and subclinical hypothyroidism is similar to that of euthyroid goiter.

Juvenile autoimmune thyroiditis

Autoimmune thyroiditis is a frequent cause of goiter in children and studies point to the increasing prevalence of juvenile autoimmune thyroiditis (JAT) in children and adolescents. Clinically, JAT can manifest, depending on the presence or absence of goiter, as either a goitrous form or atrophic form. Both are characterized by the presence of thyroid antibodies in serum, with the goitrous form being more common in children. Recent evidence suggests that thyroid autoimmunity originates from an interaction of genetic, endogenous and environmental factors which end up activating thyroid-specific autoreactive T-cells in susceptible children. In addition to underlying genetic/HLA predisposition, factors including sex hormones, glucocorticoids, low birth weight, radiation and drugs may play a role in thyroid autoimmunity. Patients with JAT can present due to thyroid enlargement or symptoms arising due to hypothyroidism. Asymptomatic enlargement of the thyroid gland is a common presenting complaint, especially in older children and adolescents. Thyroid function can vary from euthyroidism to subclinical or overt forms of hypothyroidism and less commonly hyperthyroidism. Accordingly, patients can be symptomatic. There is considerable debate regarding the management of patients with euthyroidism or subclinical hypothyroidism. Available evidence indicates the presence of residual goiter in endemic form and a high prevalence of JAT in children. It is suggested that children should be screened for goiter as part of school health examinations, and goitrous children should be monitored for thyroid function.

Long-term outcome of hormonal status in Taiwanese children with Hashimoto's thyroiditis

The objective of this prospective study was to evaluate both thyroid function in children with Hashimoto's thyroiditis and the necessity of lifetime thyroxine replacement therapy. A total of 47 patients with goiter and positive thyroid auto-antibodies participated in the study. Serum thyroxine and thyrotropin levels and titers of thyroid auto-antibodies were checked regularly throughout the follow-up period. At the beginning of the study, 25 patients were diagnosed as euthyroid, but at the end of the study, 22 patients initially diagnosed with euthyroidism remained euthyroid, while eight patients with subclinical hypothyroidism and three patients with overt hypothyroidism had become euthyroid. Thus, of the 22 patients with thyroid dysfunction at diagnosis, subclinical or overt, 11 became euthyroid during the follow-up period. The effect of thyroxine treatment on thyroid auto-antibody titers was not significant.

CONCLUSION

Our data shows that Hashimoto's thyroiditis in children has a benign course and that thyroid function in one half of the patients with thyroid dysfunction at diagnosis reverts to normal. Careful follow-up of thyroid function is important in order to determine the necessity and timing of thyroxine replacement therapy.

Natural course of autoimmune thyroiditis after elimination of iodine deficiency in northwestern Greece

We have previously reported the elimination of iodine deficiency and increasing prevalence of autoimmune thyroiditis (AIT) among schoolchildren in northwestern Greece. This study followed up 29 children (12-18 years old) with AIT for 5 years to track its course in the postiodination era. At diagnosis, thyroid peroxidase autoantibodies (TPOAbs) were positive in 25 children (86%) and became positive in all children during follow-up. Thyroglobulin autoantibodies (TgAbs) were positive in 17 children at diagnosis (59%) and became positive in 3 more children (69%). Both antibody types increased by the end of the observation period (p < 0.005). Regarding thyroid function, 7 children (24%) at diagnosis had subclinical hypothyroidism that persisted and 4 more children developed subclinical hypothyroidism during the study period (38%). Only 5 of these children (45%) had positive TgAbs. There was an increase in thyrotropin (TSH) so that at the end of the study all children had TSH greater than 2.5 mU/L but none developed overt hypothyroidism. Thyroid hypoechogenicity that increased over time was seen in all children, especially in those with subclinical hypothyroidism. In conclusion, both antibody types increased in frequency and level, but TPOAbs were the predominant autoimmunity marker predictive of impending thyroid failure in children with AIT, as was thyroid hypoechogenicity on ultrasound.

[Chronic autoimmune thyroiditis in the child]

OBJECTIVE

The aim of the study was to describe the clinical characteristics and long-term follow-up of a group of children with chronic autoimmune thyroiditis.

PATIENTS AND METHODS

Sixty children (age: 11.9 +/- 2.7 years) were studied in a retrospective analysis.

RESULTS

At diagnosis, 34 of the children were hypothyroid (compensated hypothyroidism, n = 15; true hypothyroidism, n = 19) and 26 euthyroid. Thyroid ultrasonography showed characteristic features of heterogenicity and/or hypoechogenicity in all patients. Other autoimmune diseases were found in ten subjects (17%) and 23% had a family history of thyroid disease. At the end of the follow-up, nine of 45 children (20% of the cases) followed up for at least one year (mean follow-up 4.4 +/- 3.7 years), demonstrated a change in thyroid function. Hypothyroidism was detected in two initially euthyroid patients. Among initially hypothyroid patients, seven (28%) recovered normal thyroid function, allowing L-thyroxine withdrawal for four weeks, after 1.5 to 8.4 years. No factor was found to be predictive of the course of the disease. All subjects treated with L-thyroxine for hypothyroidism reached normal final height.

CONCLUSION

The natural course of chronic lymphocytic thyroiditis is variable and unpredictable. Recovery from hypothyroidism does occur and can be aided by the L-thyroxine withdrawal test. The disease requires lifelong thyroid surveillance, especially in women during pregnancy, in order to avoid a potential adverse effect on the future child.

Prevalence of thyroid peroxidase, thyroglobulin and thyrotropin receptor antibodies in a long-term follow-up of juvenile Graves disease

OBJECTIVE

To relate the presence of thyroid peroxidase antibodies (TPO ab), thyroglobulin antibodies (Tg ab) and thyrotropin receptor antibodies (TSH-R ab) to the clinical course in a long-term follow-up of patients with juvenile Graves' disease (JGD).

DESIGN

Patients with JGD were drawn from a Danish retrospective study and reexamined.

RESULTS

A number of 105 patients were reexamined 4-21 years (median 10 years) after diagnosis. Three groups were formed: Gr.1: euthyroid patients with anti-thyroid drug (ATD) cessation more than 12 months before reexamination (n=41). Gr.2: patients still on ATD (n=24). Gr.3: subtotally thyroidectomized patients (n=40). Positive TPO ab titers were found in 75% of the patients. In 13% of the patients the titers were very high: >10,000 U/ml. Positive Tg ab were found in 51%. The prevalence of TPO ab and Tg ab was the lowest in group 3. Stimulating TSH-R ab titers were found in 13%. No patients had blocking TSH-R ab. The prevalence of TSH-R ab was 3% in the euthyroid patients, without surgery performed. 15% in the surgical patients, and 25% in the patients still on ATD.

CONCLUSIONS

Many JGD patients were euthyroid at the long-term follow-up in spite of high TPO ab and Tg ab titers. Stimulating TSH-R ab were rare (13%). According to this presence of TPO ab, Tg ab or TSH-R ab does not predict the final outcome of JGD. Further studies are needed.

The natural clinical course of children with an initial diagnosis of simple goiter: a 5-year longitudinal follow-up

A total of 154 children initially diagnosed as simple goiter were evaluated annually for 5 years. The mean age at diagnosis was 12.8 +/- 1.8 years. The annual evaluation consisted of clinical assessment for height, weight, pubertal status, goiter size, and laboratory measurements for free thyroxine (FT4), thyrotropin (TSH), anti-thyroglobulin and anti-microsomal antibodies. At initial diagnosis, goiter was grade I in 117 children (76%) and grade II in 37 children (24%). All children had normal FT4, TSH and negative thyroid antibodies. After 5 years of follow-up, there were 6 children who later had positive thyroid antibodies in the 3rd and 4th year and the diagnosis was changed to chronic lymphocytic thyroiditis. In one patient TSH level was elevated in the third year and later increased which is strongly suggestive of compensated hypothyroidism. All children had normal growth as shown by the average final adult height of 2.67 +/- 1.25 cm above the midparental height. In girls the average age at menarche was 12.5 +/- 1.4 years which was not different from normal children. The goiter decreased in size in 36 children (23.4%) and remained the same size in 113 children (73.4%) without any medication. We concluded that 1) children who were initially diagnosed as simple goiter need to be followed annually for at least 5 years, and 2) the minimal annual laboratory evaluation should be TSH and thyroid antibodies to detect the early stage of chronic lymphocytic thyroiditis and compensated hypothyroidism.

Thyroid scintigraphy in children and adolescents with Hashimoto disease

Between 1989 and 1994, 58 children and adolescents with Hashimoto thyroiditis seen at the Sainte-Justine Hospital had thyroid scintigraphy. Their medical records and films were reviewed retrospectively. Eighty-nine percent of the patients had a homogeneous distribution of tracer on thyroid scintigraphy, unlike the heterogeneous distribution classically reported in adults. In children and adolescents, thyroid scintigraphy is not helpful in the diagnosis of typical Hashimoto thyroiditis.

Chronic thyroiditis: thyroid function and histologic correlations in 601 cases

Six hundred one patients with histologically proven "chronic thyroiditis" were assessed for the correlation of thyroid function to histologic findings. The histology of chronic thyroiditis was classified into four groups (oxyphilic, mixed, focal, and hyperplastic), and the thyroid function of patients was divided into hyperthyroid, euthyroid, latent hypothyroid, and overt hypothyroid, based on the laboratory data of serum triiodothyronine (T3), thyroxine (T4), and thyrotropin (TSH) levels, as well as thyrotropin-releasing hormone (TRH) tests. In the oxyphilic group (137 cases), 116 (85%) of the patients were classified as hypothyroid: 52 (38%) as latent hypothyroid and 64 (47%) as overt hypothyroid. In the mixed group (161 cases), the thyroid function of the patients varied. Thirty-seven (23%) of the patients were classified as hyperthyroid, 61 (39%) as euthyroid, 54 (33%) as latent hypothyroid, and nine (5%) as overt hypothyroid. In this group thyroid function was intimately related to the ratio of replacement by hyperplastic-changed follicles and oxyphilic-changed follicles. In the focal group (149 cases), 123 (83%) of the patients were classified as euthyroid, while 22 (14%) were classified as latent hypothyroid. The frequency of latent hypothyroid patients increased in parallel with the severity of cell infiltration. In the hyperplastic group (154 cases), 130 (85%) of the patients were classified as hyperthyroid. In this series 19 patients under 10 years of age were included, and no difference in the distribution of histologic varieties was observed between juvenile and adult patients. Thyroid needle biopsy is a useful and safe tool, not only for the histologic diagnosis of chronic thyroiditis, but also for the evaluation of thyroid function and the identification of causes for hyperthyroidism or hypothyroidism.

Juvenile autoimmune thyroiditis and mitral valve prolapse

An increased incidence of mitral valve prolapse (MVP) has been reported in adult patients with autoimmune thyroid disease. The aim of this study was to assess the incidence of MVP in children and adolescents with juvenile autoimmune thyroiditis (JAT). Cardiac echo studies using M-mode, 2D, and Doppler examinations were performed on 23 patients (21 females, 2 males). The patients were studied at a median age of 12 years (range 5-20 years). Only one patient was found to have evidence suggestive of MVP, an incidence (4.3%) similar to that seen in the normal pediatric population. We, therefore, conclude that the incidence of MVP in children and adolescence with JAT is not increased.

Thyroiditis and acquired hypothyroidism

Chronic lymphocytic thyroiditis or Hashimoto's thyroiditis is the most common childhood cause of goiter and hypothyroidism in iodine-sufficient geographic regions.

Natural history of thyroid abnormalities: prevalence, incidence, and regression of thyroid diseases in adolescents and young adults

PURPOSE

This study reports the prevalence, incidence, and regression of thyroid abnormalities in a population observed from adolescence to adulthood.

PATIENTS AND METHODS

Examinations for thyroid abnormalities were performed in 4,819 school-age children, ages 11 to 18, in 1965 to 1968; two thirds of this original cohort (3,121) were re-examined 20 years later (1985 to 1986). Each subject with a thyroid abnormality detected by physical examination was studied by means of a series of re-examinations, and tests of thyroid function, imaging, and biopsy to determine the exact nature of the thyroid abnormality.

RESULTS

In the initial examinations (1965 to 1968), 185 thyroid abnormalities were found (3.7%). Diffuse hypertrophy with normal function (adolescent goiter) was the most common abnormality (19.3/1,000); 12.7/1,000 had chronic lymphocytic thyroiditis, and 4.6/1,000 had thyroid nodules, including two papillary carcinomas. Hyperthyroidism or hypothyroidism was found in 1.9/1,000. In the follow-up examinations in 1985 to 1986, 298 subjects had thyroid abnormalities (10.5%), of whom 81 (28.7/1,000) had simple goiters, 145 (51.3/1,000) had chronic thyroiditis, 45 (15.9/1,000) had hypothyroidism, 11 (3.9/1,000) had hyperthyroidism, and 66 (23.2/1,000) had nodules, which included 10 carcinomas. Of the 92 subjects with simple or adolescent goiter in 1965 to 1968, 60% were normal by 1985 to 1986, 20% were unchanged, and a few had developed thyroiditis (10%) or colloid goiters (3.0%). Of 61 subjects with thyroiditis, 27% had become normal, 33% remained unchanged, and 33% had become hypothyroid. Of the 22 subjects with thyroid nodules, two had complete disappearance of the nodules, and three had nodules considered to be variants of normal. The others exhibited a variety of nodular pathologic conditions.

CONCLUSIONS

The natural history of thyroid disorders, including simple goiter, chronic thyroiditis, hyperthyroidism, hypothyroidism, and nodular diseases of the thyroid, indicates they are dynamic and changeable in form, function, appearance, and disappearance.

Comparison of atrophic and goitrous auto-immune thyroiditis in children: clinical, laboratory and TSH-receptor antibody studies

We studied the clinical features, laboratory and thyroid functions and thyrotropin (TSH)-receptor and thyroid-stimulation antibodies in 21 patients with atrophic auto-immune thyroiditis (AAT) and 48 patients with goitrous auto-immune thyroiditis (GAT) of childhood onset. The clinical features of patient with AAT were cessation of growth and obesity, while asymptomatic enlargement of the thyroid gland was the sole symptom in most patients with GAT. Although the ages at diagnosis were comparable in both groups, the estimated ages at onset were much lower in patients with AAT than in those with GAT. Patients with AAT exhibited more severe hypothyroidism when evaluated by serum thyroxine (T4), tri-iodothyronine (T3), TSH, cholesterol levels and basal metabolic rates. The 24 h 123I-thyroidal uptake was significantly lower in patients with AAT than in those with GAT. None of the 19 patients with AAT possessed TSH-binding inhibitor immunoglobulins (TBII). On the other hand, 3 of the 32 GAT patients tested, possessed weak to potent TBII activities. Three TBII-positive patients with GAT also possessed thyroid-stimulation blocking antibodies. These findings suggest that: 1. Pathogenesis of AAT in children whose onset of hypothyroidism was before puberty is not due to TSH-receptor blocking antibodies, which are often found in patients with AAT of postpubertal onset. 2. AAT in children is considered not to be due to the later stage of GAT. 3. Some patients with GAT possessed TSH-receptor blocking antibodies. The aetiology and pathogenesis of AAT in children have yet to be elucidated.

Thyroid infiltrating cells in juvenile autoimmune thyroiditis: a follow-up of 1 year

The composition of the cellular infiltrate in thyroid glands of 12 patients with juvenile autoimmune thyroiditis (JAIT) was followed for a period of 1 year. The diagnosis of JAIT was based on a firm goiter and on cytologic criteria of lymphocytic thyroiditis. Samples from the thyroid gland were obtained by fine-needle aspiration biopsy three times at 6-month intervals. Lymphocytes with a few lymphoid blasts and plasma cells dominated the cellular infiltrate. The relative number of the different cell types remained unchanged during the follow-up time of 1 year. Analysis of the lymphocytes revealed that about 60% of the infiltrating lymphoid cells were T cells and about 30% expressed B-cell markers. The T helper/suppressor ratio was significantly higher in the thyroid (2.2) than in the corresponding blood sample (1.2). Practically no changes were seen in the proportions of lymphocyte subclasses either in the gland or in the blood of the patients during the follow-up. At the time of diagnosis more than half of lymphocytes in the thyroid were HLA class II positive as were most of the glandular epithelial cells. The proportion of cells expressing class II was similar in samples taken at diagnosis and 6 and 12 months later, indicating a continuous state of immunoactivation in the thyroid gland.

Alopecia areata, endocrine function, and autoantibodies in patients 16 years of age or younger

Forty-five children with alopecia areata were prospectively studied by means of both clinical and laboratory evaluation for evidence of endocrine diseases and autoantibodies. Twenty-four percent had an abnormality as determined by one or more thyroid function studies (thyroxine, triiodothyronine, and thyroid-stimulating hormone) and/or elevation of microsomal antibody levels. In 16%, smooth muscle antibody was present, and in 4%, parietal cell antibody was present. Routine thyroid function testing is recommended for all children with alopecia areata.