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Ultrasound determination of pediatric thyroid mass. Pediatr Radiol 2023; 53:28-33. [PMID: 35881167 DOI: 10.1007/s00247-022-05450-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 06/01/2022] [Accepted: 06/30/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Radioiodine therapy for Graves disease can be achieved with dosing based on estimated thyroid gland mass. Thyroid mass can be estimated using linear ultrasound measurements, and conversion factors for volume and density. The choice of conversion factors could impact estimated thyroid mass and thus administered radioiodine dose. OBJECTIVE The objective of this study was to define the relationship between thyroid mass estimated by ultrasound and measured thyroid mass following thyroidectomy. MATERIALS AND METHODS This was a retrospective, exempt study that included patients < 18 years of age with < 6 months between thyroid ultrasound and thyroidectomy January 2010-June 2020. Thyroid dimensions by ultrasound, thyroid mass at thyroidectomy and histopathological diagnosis were collected. Published conversion factors were used to estimate thyroid volume with conversion to mass using a density of 1.05 g/cm3. Pearson correlations and Bland-Altman difference analyses were used to define the relationship between estimated mass and specimen weight. Linear regression was used to calculate an optimal conversion factor for estimating thyroid mass. RESULTS We included 86 patients, 67 female (78%), with a mean age of 14.5 ± 3.15 years. Mass estimated using all tested conversion factors had similar strong, positive correlation with specimen weight (r = 0.95). The mean difference between thyroid mass estimated by ultrasound and measured mass ranged from - 0.34 g (conversion factor = 0.523) to 1.69 g (conversion factor = 0.554). The optimal simplified factor for estimation of thyroid mass for the study sample was 0.537. CONCLUSION All published conversion factors for estimating thyroid mass based on linear ultrasound measurements produce good estimates of thyroid mass. Errors in estimated mass are less than 2 g on average.
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Mooij CF, Cheetham TD, Verburg FA, Eckstein A, Pearce SH, Léger J, van Trotsenburg ASP. 2022 European Thyroid Association Guideline for the management of pediatric Graves' disease. Eur Thyroid J 2022; 11:e210073. [PMID: 34981748 PMCID: PMC9142815 DOI: 10.1530/etj-21-0073] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/04/2021] [Indexed: 11/15/2022] Open
Abstract
Hyperthyroidism caused by Graves' disease (GD) is a relatively rare disease in children. Treatment options are the same as in adults - antithyroid drugs (ATD), radioactive iodine (RAI) or thyroid surgery, but the risks and benefits of each modality are different. The European Thyroid Association guideline provides new recommendations for the management of pediatric GD with and without orbitopathy. Clinicians should be alert that GD may present with behavioral changes or declining academic performance in children. Measurement of serum TSH receptor antibodies is recommended for all pediatric patients with hyperthyroidism. Management recommendations include the first-line use of a prolonged course of methimazole/carbimazole ATD treatment (3 years or more), a preference for dose titration instead of block and replace ATD, and to avoid propylthiouracil use. Where definitive treatment is required either total thyroidectomy or RAI is recommended, aiming for complete thyroid ablation with a personalized RAI activity. We recommend avoiding RAI in children under 10 years of age but favor surgery in patients with large goiter. Pediatric endocrinologists should be involved in all cases.
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Affiliation(s)
- Christiaan F Mooij
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Correspondence should be addressed to C F Mooij or A S P van Trotsenburg: or
| | - Timothy D Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
- Department of Pediatric Endocrinology, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - Frederik A Verburg
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Anja Eckstein
- Department of Ophthalmology, University Duisburg Essen, Essen, Germany
| | - Simon H Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
- Endocrine Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - Juliane Léger
- Department of Pediatric Endocrinology and Diabetes, Reference Center for Rare Endocrine Growth and Development Diseases, Endo-ERN HCP, Assistance Publique-Hôpitaux de Paris, Robert Debré University Hospital, University of Paris, NeuroDiderot Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - A S Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Correspondence should be addressed to C F Mooij or A S P van Trotsenburg: or
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Abstract
The term 'hyperthyroidism' refers to a form of thyrotoxicosis due to inappropriate high synthesis and secretion of thyroid hormone(s) by the thyroid. The leading cause of hyperthyroidism in adolescents is Graves' disease (GD); however, one should also consider other potential causes, such as toxic nodular goitre (single or multinodular), and other rare disorders leading to excessive production and release of thyroid hormones. The term 'thyrotoxicosis' refers to a clinical state resulting from inappropriate high thyroid hormone action in tissues, generally due to inappropriate high tissue thyroid hormone levels. Thyrotoxicosis is a condition with multiple aetiologies, manifestations, and potential modes of therapy. By definition, the extrathyroidal sources of excessive amounts of thyroid hormones, such as iatrogenic thyrotoxicosis, factitious ingestion of thyroid hormone, or struma ovarii, do not include hyperthyroidism. The aetiology of hyperthyroidism/and thyrotoxicosis should be determined. Although the diagnosis is apparent based on the clinical presentation and initial biochemical evaluation, additional diagnostic testing is indicated. This testing should include: (1) measurement of thyroid-stimulating hormone receptor (TSHR) antibodies (TRAb); (2) analysis of thyroidal echogenicity and blood flow on ultrasonography; or (3) determination of radioactive iodine uptake (RAIU). A 123I or 99mTc pertechnetate scan is recommended when the clinical presentation suggests toxic nodular goitre. A question arises regarding whether diagnostic workup and treatment (antithyroid drugs, radioiodine, surgery, and others) should be the same in children and adolescents as in adults, as well as whether there are the same goals of treatment in adolescents as in adults, in female patients vs in male patients, and in reproductive or in postreproductive age. In this aspect, different treatment modalities might be preferred to achieve euthyroidism and to avoid potential risks from the treatment. The vast majority of patients with thyroid disorders require life-long treatment; therefore, the collaboration of different specialists is warranted to achieve these goals and improve patients' quality of life.
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Affiliation(s)
- Marek Niedziela
- Department of Pediatric Endocrinology and Rheumatology, Institute of Pediatrics, Karol Jonscher’s Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
- Correspondence should be addressed to M Niedziela:
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Costa STB, Albino V, Peres A, Ferreira P. Graves' disease in a patient with Down syndrome: a shift from hyperthyroidism to hypothyroidism. BMJ Case Rep 2021; 14:e242612. [PMID: 34518175 PMCID: PMC8438817 DOI: 10.1136/bcr-2021-242612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 11/03/2022] Open
Abstract
Down syndrome (DS) is associated with an increased risk of multisystemic dysfunction, namely endocrine abnormalities. Thyroid dysfunction is the most common endocrinological disorder, and it can manifest as either hypothyroidism or hyperthyroidism. A 16-year-old patient with DS developed hyperthyroidism after a lifetime of alternating between subclinical hypothyroidism and euthyroidism. He presented new onset weight loss, agitation and diarrhoea. Laboratory studies were compatible with hyperthyroidism. Thyroid receptor antibodies (TRAbs) were positive, antithyroid peroxidase antibodies and thyroglobulin antibodies were negative. Antithyroid medication (methimazole) was prescribed and, despite therapy adjustments, laboratory evaluation revealed new onset hypothyroidism with persistently positive TRAbs. He experienced weight gain and remained in a hypothyroid state even with withdrawal of methimazole and administration of levothyroxine. This case illustrates an example of Graves' disease with coexisting stimulating and inhibiting TRAbs that led to a shift from hyperthyroidism to hypothyroidism, a rare condition in patients with DS.
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Affiliation(s)
- Sara Todo Bom Costa
- Pediatrics Deparment-HVFX, CUF, José Mello Saude Group, CUF, Carnaxide, Portugal
- Pediatrics Department, Santa Maria Hospital, Northern Lisbon University Hospital Centre, Lisbon, Portugal
| | - Vanessa Albino
- Pediatrics Deparment-HVFX, CUF, José Mello Saude Group, CUF, Carnaxide, Portugal
| | - Ana Peres
- Pediatrics Deparment-HVFX, CUF, José Mello Saude Group, CUF, Carnaxide, Portugal
| | - Patrícia Ferreira
- Pediatrics Deparment-HVFX, CUF, José Mello Saude Group, CUF, Carnaxide, Portugal
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Alex-Ann Beliard K, Shyamkumar S, Brar PC, Rapaport R. Graves disease in infancy: a patient presentation and literature review. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM200162. [PMID: 34156351 PMCID: PMC8240725 DOI: 10.1530/edm-20-0162] [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: 03/28/2021] [Accepted: 05/24/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY We describe a case of an infant who presented with clinical features of hyperthyroidism. The child was found to be tachycardic, hypertensive and diaphoretic, she was noted to have poor weight gain and difficulty in sleeping. The child was admitted to the pediatric intensive care unit for care. She was found to have biochemical evidence of hyperthyroidism with positive thyroid stimulating immunoglobulin. She responded well to methimazole and propranolol and had a remarkable recovery. She is the youngest patient to be diagnosed with Graves disease in the English literature, at 12 months of life. LEARNING POINTS Hyperthyroidism must always be considered even at very young age, for patient presenting with poor weight gain and hyperdynamic state. Autoimmune diseases are becoming more common in infancy. Craniosynostosis and increased height for age are well-documented consequences of untreated hyperthyroidism in developing children.
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Affiliation(s)
- Kara Alex-Ann Beliard
- Icahn School of Medicine, Mount Sinai Department of Pediatric Endocrinology, Kravis Children's Hospital, New York, NY, USA
| | | | - Preneet Cheema Brar
- Division of Pediatric Endocrinology, New York University Grossman School of Medicine, New York, NY, USA
| | - Robert Rapaport
- Icahn School of Medicine, Mount Sinai Department of Pediatric Endocrinology, Kravis Children's Hospital, New York, NY, USA
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Mizokami T, Hamada K, Maruta T, Higashi K, Tajiri J. Long-Term Outcomes of Radioiodine Therapy for Juvenile Graves Disease with Emphasis on Subsequently Detected Thyroid Nodules: A Single Institution Experience from Japan. Endocr Pract 2020; 26:729-737. [PMID: 33471641 DOI: 10.4158/ep-2019-0468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 02/13/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the long-term outcomes of radioiodine therapy (RIT) for juvenile Graves disease (GD) and the ultrasonographic changes of the thyroid gland. METHODS All of 117 juvenile patients (25 males and 92 females, aged 10 to 18 [median 16] years) who had undergone RIT for GD at our clinic between 1999 and 2018 were retrospectively reviewed. Each RIT session was delivered on an outpatient basis. The maximum 131I dose per treatment was 13.0 mCi, and the total 131I dose per patient was 3.6 to 29.8 mCi (median, 13.0 mCi). 131I administration was performed once in 89 patients, twice in 26, and three times in 2 patients. Ultrasonography of the thyroid gland was regularly performed after RIT. The duration of follow-up after the initial RIT ranged from 4 to 226 (median 95) months. RESULTS At the latest follow-up more than 12 months after RIT (n = 111), the patients' thyroid functions were overt hypothyroidism (91%), subclinical hypothyroidism (2%), normal (5%), or subclinical hyperthyroidism (2%). New thyroid nodules were detected in 9 patients, 4 to 17 years after initial RIT. Patients with newly detected thyroid nodules underwent RIT with lower doses of 131I and had larger residual thyroid volumes than those without nodules. None of the patients were diagnosed with thyroid cancer or other malignancies during the follow-up period. CONCLUSION Over a median follow-up period of 95 months (range, 4 to 226 months), RIT was found to be effective and safe in juvenile GD. However, cumulative evidence from further studies is required to confirm the long-term safety of RIT for juvenile GD. ABBREVIATIONS ATD = antithyroid drug; GD = Graves disease; KI = potassium iodide; LT4 = levothyroxine; MMI = methimazole; PTU = propylthiouracil; RAIU = radio-active iodine uptake; RIT = radioiodine therapy; 99mTc = technetium-99m; TSH = thyrotropin.
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Aggarwal S, Fogel J, Kumar K, Shabbir N. Trauma and thyroid-stimulating hormone abnormalities in pediatric patients. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408619845766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background There is limited literature on trauma and endocrine abnormalities in the pediatric trauma setting. Aim We studied demographic, medical history, injury experience, and mortality factors to determine their association with abnormal thyroid-stimulating hormone in pediatric trauma patients. Methods The 414 pediatric trauma patients were from those seen at an emergency department. The primary outcome variable was abnormal thyroid-stimulating hormone. Secondary outcome variables were abnormal high and abnormal low thyroid-stimulating hormone. Predictor variables were demographics (age, sex, race/ethnicity, body mass index), medical history (thyroid disease, diabetes mellitus, autoimmune disease, psychiatric disease), injury experience (injury cause, injury severity score ≥ 15, moderate/severe traumatic brain injury, length of stay), and mortality (mortality, survival probability). Multivariate logistic regression analyses were conducted. Results There were 8.0% ( n = 33) with any abnormal thyroid-stimulating hormone value. In the analysis for abnormal thyroid-stimulating hormone, females (odds ratio:4.95, 95% confidence interval: 2.01, 12.21, p < 0.01) and traumatic brain injury (odds ratio: 8.11, 95% confidence interval: 2.51, 26.16, p < 0.001) were each significantly associated with increased odds. In the analysis for abnormal high thyroid-stimulating hormone (odds ratio: 3.75, 95% confidence interval: 1.37, 10.24, p < 0.05), traumatic brain injury (odds ratio: 11.59, 95% confidence interval: 3.45, 38.97, p < 0.001), and mortality (odds ratio: 35.59, 95% confidence interval: 1.40, 906.57, p < 0.05) were each significantly associated with increased odds. In the analysis for abnormal low thyroid-stimulating hormone, only females (odds ratio: 11.10, 95% confidence interval: 1.26, 97.60, p < 0.05) were significantly associated with increased odds. Conclusion In conclusion, females and traumatic brain injury have increased odds for abnormal thyroid-stimulating hormone. Mortality has increased odds for abnormal high thyroid-stimulating hormone. We suggest that clinicians in the pediatric trauma setting carefully monitor females and traumatic brain injury patients with abnormal thyroid-stimulating hormone.
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Affiliation(s)
- Shefali Aggarwal
- Department of Pediatrics, Nassau University Medical Center, East Meadow, NY, USA
| | - Joshua Fogel
- Department of Pediatrics, Nassau University Medical Center, East Meadow, NY, USA
- Department of Business Management, Brooklyn College, Brooklyn, NY, USA
| | - Krishan Kumar
- Department of Pediatrics, Nassau University Medical Center, East Meadow, NY, USA
| | - Nadeem Shabbir
- Department of Pediatrics, Nassau University Medical Center, East Meadow, NY, USA
- Department of Pediatrics, New York College of Osteopathic Medicine, New York, NY, USA
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Kim H, Lee J, Ha J. A case of antithyroid drug-induced agranulocytosis from a second antithyroid drugs (ATD) administration in a relapsed Graves' disease patient who was tolerant to the first ATD treatment. Clin Case Rep 2018; 6:1701-1703. [PMID: 30214745 PMCID: PMC6132132 DOI: 10.1002/ccr3.1644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/04/2018] [Accepted: 05/27/2018] [Indexed: 11/26/2022] Open
Abstract
Agranulocytosis is a rare side effect of antithyroid drugs (ATD) that usually develops within the first 3-6 months after starting treatment. We present a 64-year-old patient who developed agranulocytosis after starting ATD to treat relapsed Graves' disease. This patient had tolerated the first course of ATD for 72 months. This was an unusual case in which a serious side effect developed during a second ATD course. It is essential that clinicians remain vigilant to the fact that antithyroid drugs can induce agranulocytosis several years after initiated.
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Affiliation(s)
- Hyunsam Kim
- Division of Endocrinology and MetabolismDepartment of Internal MedicineCollege of MedicineSeoul St. Mary's HospitalThe Catholic University of KoreaSeoulKorea
| | - Jeongmin Lee
- Division of Endocrinology and MetabolismDepartment of Internal MedicineCollege of MedicineSeoul St. Mary's HospitalThe Catholic University of KoreaSeoulKorea
| | - Jeonghoon Ha
- Division of Endocrinology and MetabolismDepartment of Internal MedicineCollege of MedicineSeoul St. Mary's HospitalThe Catholic University of KoreaSeoulKorea
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Léger J, Oliver I, Rodrigue D, Lambert AS, Coutant R. Graves' disease in children. ANNALES D'ENDOCRINOLOGIE 2018; 79:647-655. [PMID: 30180972 DOI: 10.1016/j.ando.2018.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
R1 The diagnosis of Graves' disease in children is based on detecting a suppression of serum TSH concentrations and the presence of anti-TSH receptor antibodies. 1/+++. R2 Thyroid ultrasound is unnecessary for diagnosis, but can be useful for assessing the size and homogeneity of the goiter. 2/+. R3. Thyroid scintigraphy is not required for the diagnosis of Graves' disease. 1/+++. R4. The measurement of T4L and T3L levels is not necessary for the diagnosis of Graves' disease in children but can be useful for the management and assessment of prognosis. 1/++. R5. In the absence of TSH receptor autoantibodies, the possibility of genetically inherited hyperthyroidism must be considered. 1/++. R6. Drug therapy is the primary line of treatment for children and consists of imidazole, carbimazole or thiamazole, with an initial dosage of 0.4 to 0.8mg/kg/day (0.3 to 0.6mg/kg/day for thiamazole) depending on the initial severity, up to maximum of 30mg. 1/++. R7. Propylthiouracil is contraindicated for children with Grave's disease. 1/+++. R8. Before starting treatment, it may be useful to perform a CBC in order to assess the degree of neutropenia caused by hyperthyroidism. It is not necessary to perform systematic CBCs during follow-up. 2/+. R9. An emergency CBC should be performed if symptoms include fever or angina. If neutrophil counts are <1000/mm3, synthetic antithyroid therapy should be discontinued or decreased and may be permanently contraindicated in severe (<500) and persistent neutropenia. Otherwise treatment may be resumed. 1/++. R10. Transaminases levels should be measured before initiating treatment. Systematic monitoring of liver function is not consensually validated. 2/+. R11. In cases of jaundice, digestive disorders or pruritus, measuring liver enzymes (AST, ALT), total and conjugated bilirubin and alkaline phosphatases is indicated. 1/++. R12. Patients and parents should be informed of the possible side effects of antithyroid agents. 1/+. R13. Therapeutic education of parents and children is important in ensuring the best possible treatment compliance. 2/++. R14. Given the specificities involved in the treatment of Graves' disease in children, medical care should be provided by a specialist accustomed to treating endocrinopathies in pediatric patients. 2/+. R15. Depending on patient age, the severity of the disease at diagnosis and the persistence of anti-TSH receptor antibodies, the initial course of treatment must take place over an extended period of 3 to 6 years. R16.The anticipated success rates of medical treatment (50% of patients in remission following several years of treatment) should be explained to the family and the child. The possibility that radical treatment may be required in case of failure or intolerance of medical treatment should also be discussed. 1/++. R17.In females with Graves' disease, it is important to explain that they must undergo an assessment by an endocrinologist before planning future pregnancies, from the start of pregnancy and during the course of pregnancy. This is true in all female patients, even those in remission after medical treatment, or those who have undergone radical treatment. R18.Indications for a radical treatment can arise in cases of: 1/+: contraindication to antithyroid agents; poorly controlled hyperthyroidism due to lack of compliance; relapse despite prolonged medical treatment; a request made by the family and child for personal reasons. R19.Surgery is the radical method of treatment used in children under 5 years of age, or in cases of very large, nodular, or compressive goiters. 2/++. R20. The surgeon's experience in dealing with thyroidectomies in children is likely to be the most significant determining factor in limiting the morbidity of the procedure (alongside any collaboration between a pediatric surgeon and an adult surgeon). 1/++. R21 When radical treatment is indicated, I-131 treatment may be discussed after 5 years (but more often after puberty), if the goiter is not too large. Experience from monitoring Graves' disease in North American children is reassuring. 1/++.
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Affiliation(s)
- Juliane Léger
- Department of Pediatric Endocrinology and Diabetology and Reference Center for rare Diseases of Growth and Development, CHU Robert-Debre, 75019 Paris, France
| | - Isabelle Oliver
- Endocrine, Bone Diseases, Genetics, Obesity, and Gynecology Unit, Children's Hospital, University Hospital, 31000 Toulouse, France
| | - Danielle Rodrigue
- Department of Pediatric Endocrinology, CHU Bicêtre, 94275 Le Kremlin-Bicêtre, France
| | - Anne-Sophie Lambert
- Department of Pediatric Endocrinology, CHU Bicêtre, 94275 Le Kremlin-Bicêtre, France
| | - Régis Coutant
- Department of Pediatric Endocrinology and Diabetology and Reference Center for Rare Diseases of Thyroid and Hormone Receptivity, University hospital of Angers, 4, rue Larrey, 49933 Angers cedex 9, France.
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Kourime M, McGowan S, Al Towati M, Ahmed SF, Stewart G, Williamson S, Hunter I, Donaldson MDC. Long-term outcome of thyrotoxicosis in childhood and adolescence in the west of Scotland: the case for long-term antithyroid treatment and the importance of initial counselling. Arch Dis Child 2018; 103:637-642. [PMID: 29269558 PMCID: PMC6047164 DOI: 10.1136/archdischild-2017-313454] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 11/22/2017] [Accepted: 11/27/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Thyrotoxicosis is both rarer and more severe in children than in adults, rendering management difficult and often unsatisfactory. OBJECTIVE To ascertain outcome in a geographically defined area of Scotland between 1989 and 2014. METHOD Retrospective case note review with follow-up questionnaire to family doctors for patients with Graves' disease and Hashimoto's thyroiditis. RESULTS Sixty-six patients (58 females:8 males) comprising 53 with Graves' disease and 13 with Hashimoto's thyroiditis were diagnosed at median 10.4 (2.9-15.8) years and followed up for 11.8 (2.6-30.2) years. Antithyroid drug (ATD) therapy was stopped electively in 35 patients after 4.5 (1.5-8.6) years, resulting in remission in 10/13 Hashimoto's thyroiditis and 10/22 Graves' disease. Side effects occurred in 12 patients receiving carbimazole, six of whom changed to propylthiouracil; no adverse events occurred in the latter patients.Second-line therapy was given to 37 patients (34 with Graves' disease), comprising radioiodine (22) at 15.6 (9.3-24.4) years for relapse (6), poor control/adherence (14) or electively (2); and surgery (16) at 12 (6.4-21.3) years for relapse (4), poor control/adherence (5) and electively (7). Adherence problems with thyroxine replacement were reported in 10/33 patients in adulthood. CONCLUSIONS Hashimoto's thyroiditis should be distinguished from Graves' disease at diagnosis since the prognosis for remission is better. Remission rates for Graves' disease are low (10/53 patients), time to remission variable and adherence with both ATD and thyroxine replacement often problematic. We recommend (a) the giving of long-term ATD rather than a fixed course of treatment in GD and (b) meticulous and realistic counselling of families from the time of diagnosis onwards.
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Affiliation(s)
- Mariam Kourime
- University Hospital Abderrahim Harouchi, Casablanca, Morocco
| | - Sheena McGowan
- Child Health Section, Glasgow University School of Medicine, Royal Hospital for Sick Children, Glasgow, UK
| | - Mabrouka Al Towati
- Child Health Section, Glasgow University School of Medicine, Royal Hospital for Sick Children, Glasgow, UK
| | - S Faisal Ahmed
- Child Health Section, Glasgow University School of Medicine, Royal Hospital for Sick Children, Glasgow, UK
| | | | | | - Iain Hunter
- Wishaw General Hospital, Lanarkshire, Scotland, UK
| | - Malcolm D C Donaldson
- Child Health Section, Glasgow University School of Medicine, Royal Hospital for Sick Children, Glasgow, UK
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Surgical Management of Thyroid Disease in Children. CURRENT OTORHINOLARYNGOLOGY REPORTS 2018. [DOI: 10.1007/s40136-018-0189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Marques O, Antunes A, Oliveira MJ. Treatment of Graves' disease in children: The Portuguese experience. ACTA ACUST UNITED AC 2018; 65:143-149. [PMID: 29325833 DOI: 10.1016/j.endinu.2017.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 11/01/2017] [Accepted: 11/09/2017] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Graves' disease (GD) is an autoimmune thyroid disease, common in adults but rare in children. The best therapeutic approach remains controversial. OBJECTIVES To ascertain the current treatment of pediatric GD in Portugal and to assess the clinical and biochemical factors that determine definitive/long-term remission after treatment with antithyroid drugs (ATDs). PATIENTS AND METHODS A retrospective analysis of data about pediatric GD treatment collected from a nationwide survey conducted by the Portuguese Society of Pediatric Endocrinology and Diabetology from May to August 2013. Population was categorized based on sex, age, use of ATDs, dosage, treatment duration, adverse reactions, thyrotropin receptor-stimulating antibody (TRAB) titer, remission and remission/relapse rates, and definitive treatment, and divided into group A (with ongoing treatment) and group B (with treatment stopped). Group B was subdivided into 'Remission', 'Remission+relapse' and 'No remission' subgroups based on the course of disease. The same parameters were compared between both groups. RESULTS Survey response rate was 77%; 152 subjects, 116 female, mean age at diagnosis 11.23±3.46 years. They all started treatment with ATDs, 70.4% with thiamazole, with a mean treatment duration of 32.38±28.29 months, and 5.9% had adverse effects. Remission rate was 32.6%. Lower age at diagnosis correlated with higher remission rates. Treatment duration was longer when propylthiouracil was used. Initial TRAB titer was significantly higher in the 'No remission' group. Surgery and radioiodine were used as second-line treatments. CONCLUSION Our study results were similar to those reported in the literature. Age and TRAB titer were identified as potential clinical and laboratory determinants of remission. Based on risk/benefit analysis, it was concluded that treatment should be individualized based on age, accessibility to treatments, and physician's experience.
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Affiliation(s)
- Olinda Marques
- Division of Endocrinology, Hospital de Braga, Portugal; Portuguese Society of Pediatric Endocrinology and Diabetology, Portugal.
| | - Ana Antunes
- Division of Pediatric, Hospital de Braga, Portugal; Portuguese Society of Pediatric Endocrinology and Diabetology, Portugal
| | - Maria João Oliveira
- Division of Endocrinology, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal; Portuguese Society of Pediatric Endocrinology and Diabetology, Portugal
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Wong SC, Zacharin M. Long-term health outcomes of adults with McCune-Albright syndrome. Clin Endocrinol (Oxf) 2017; 87:627-634. [PMID: 28699175 DOI: 10.1111/cen.13419] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 06/19/2017] [Accepted: 07/06/2017] [Indexed: 12/15/2022]
Abstract
CONTEXT McCune-Albright syndrome (MAS) is associated with numerous health problems. Comprehensive long-term health problems of adults with MAS are less well defined in the literature. OBJECTIVE Our objective is to report comprehensive health outcomes of adults with MAS (>18 years). DESIGN Retrospective case note review of 16 adults with MAS managed by one clinician. Results expressed as median (range). RESULTS The study included 16 adults (seven males) with MAS. Median current age is 29 years (20, 46). Twelve of 16 had craniofacial fibrous dysplasia with five of 12 (42%) with progressive facial asymmetry. Growth hormone excess was observed in six of 16 (38%) and T3-toxicosis in five of 16 (31.3%). Six of the seven men (86%) had abnormalities on testicular ultrasound with one man exhibiting marked atrophy of germ and sertoli cells with reduction in spermatogenesis. Six of the 16 (38%) had cardiorespiratory complications including high output cardiac failure (n,3), hypertension (n,2) and one man with congestive cardiac failure and restrictive lung disease. Six of eight (66%) who had screening endoscopy for upper gastrointestinal polyps show increasing numbers of polyps, with benign histology to date. One woman with a previous history of early puberty presented with early aggressive breast carcinoma, which was positive for GNAS. Two patients had GNAS-positive muscle myomas. Platelet dysfunction with bleeding tendency responsive to platelet transfusion during surgery was seen in four. CONCLUSION A range of complex health problems is encountered in adults with MAS. These have important implications for transition of patients with MAS and adult care. Long-term cancer risk is currently unknown but requires careful follow-up.
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Affiliation(s)
- Sze Choong Wong
- Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow, UK
| | - Margaret Zacharin
- Department of Endocrinology, The Royal Children's Hospital, Melbourne, VIC, Australia
- Centre for Hormone Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
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Minamitani K, Sato H, Ohye H, Harada S, Arisaka O. Guidelines for the treatment of childhood-onset Graves' disease in Japan, 2016. Clin Pediatr Endocrinol 2017; 26:29-62. [PMID: 28458457 PMCID: PMC5402306 DOI: 10.1297/cpe.26.29] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/02/2016] [Indexed: 12/12/2022] Open
Abstract
Purpose behind developing these guidelines: Over one decade ago, the “Guidelines for the
Treatment of Graves’ Disease with Antithyroid Drug, 2006” (Japan Thyroid Association
(JTA)) were published as the standard drug therapy protocol for Graves’ disease. The
“Guidelines for the Treatment of Childhood-Onset Graves’ Disease with Antithyroid Drug in
Japan, 2008” were published to provide guidance on the treatment of pediatric patients.
Based on new evidence, a revised version of the “Guidelines for the Treatment of Graves’
Disease with Antithyroid Drug, 2006” (JTA) was published in 2011, combined with the
“Handbook of Radioiodine Therapy for Graves’ Disease 2007” (JTA). Subsequently, newer
findings on pediatric Graves’ disease have been reported. Propylthiouracil (PTU)-induced
serious hepatopathy is an important problem in pediatric patients. The American Thyroid
Association’s guidelines suggest that, in principle, physicians must not administer PTU to
children. On the other hand, the “Guidelines for the Treatment of Graves’ Disease with
Antithyroid Drug, 2011” (JTA) state that radioiodine therapy is no longer considered a
“fundamental contraindication” in children. Therefore, the “Guidelines for the Treatment
of Childhood-Onset Graves’ Disease with Antithyroid Drug in Japan, 2008” required
revision.
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Affiliation(s)
| | - Kanshi Minamitani
- Department of Pediatrics, Teikyo University Chiba Medical Center, Chiba, Japan
| | | | - Hidemi Ohye
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | - Shohei Harada
- Division of Neonatal Screening, National Center for Child Health and Development, Tokyo, Japan
| | - Osamu Arisaka
- Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
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Hanba C, Svider PF, Siegel B, Sheyn A, Shkoukani M, Lin HS, Raza SN. Pediatric Thyroidectomy. Otolaryngol Head Neck Surg 2016; 156:360-367. [PMID: 28145836 DOI: 10.1177/0194599816677527] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objectives/Hypothesis To evaluate hospital course and associated complications among pediatric patients undergoing thyroidectomy. Study Design and Setting Retrospective database review of the Kids' Inpatient Database (2009, 2012). Methods The Kids' Inpatient Database was evaluated for thyroidectomy patients for the years 2009 and 2012. Surgical procedure, patient demographics, length of stay, hospital charges (in US dollars), and surgical complications were evaluated. Results Of an estimated 1099 nationwide partial thyroidectomies and 1654 total thyroidectomies, females accounted for 73.5% and 79.1% of patients, respectively. Children <1 year of age had significantly longer hospital courses ( P < .0001), and patients 1 to 5 years of age had a significantly greater length of stay than individuals 6 to 20 years of age (7.8 vs 2.1 days, P < .001). The most common complications overall included hypocalcemia, respiratory complications, vocal cord paresis/paralysis, postoperative infection, and bleeding. Vocal cord paralysis was noted in 1.7% of pediatric thyroidectomy patients. The presence of these complications among total thyroidectomy patients significantly increased one's length of stay and hospital charges. A neck dissection was reported in 22.9% of malignant thyroidectomy patients. Conclusion Nearly 20% of children who underwent total thyroidectomy experienced postoperative hypocalcemia, positing a need for the development of postoperative calcium replacement algorithms to minimize the sequelae of hypocalcemia. A greater incidence of respiratory and infectious complications among younger patients (<6 years) suggests a need for closer monitoring, possibly encompassing routine postoperative intensive care unit utilization, in an attempt to minimize these sequelae.
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Affiliation(s)
- Curtis Hanba
- 1 Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Peter F Svider
- 1 Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Bianca Siegel
- 1 Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA.,2 Children's Hospital of Michigan, Detroit Medical Center, Detroit, Michigan, USA
| | - Anthony Sheyn
- 3 Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,4 Department of Pediatric Otolaryngology, LeBonheur Children's Hospital, Memphis, Tennessee, USA
| | - Mahdi Shkoukani
- 1 Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA.,5 Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, USA
| | - Ho-Sheng Lin
- 1 Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA.,5 Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, USA
| | - S Naweed Raza
- 1 Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA.,5 Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, USA
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Puthenpura V, Desai K, Bauer A, Marshall I. Delayed methimazole-induced agranulocytosis in a 6-year old patient with Graves’ disease. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2016; 2016:16. [PMID: 27605984 PMCID: PMC5013617 DOI: 10.1186/s13633-016-0034-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 08/24/2016] [Indexed: 11/10/2022]
Abstract
Background Agranulocytosis is regarded as a rare side effect of methimazole (MMI) therapy that occurs in a dose dependent manner and that usually develops within the first 3–6 months of treatment. Although delayed development beyond this timeline has been documented in adults, very few children have been reported with this presentation. Case presentation We present a 6-year old patient who developed agranulocytosis 18 months after the start of MMI therapy. Conclusions This is an unusual case of a 6-year old patient who developed this serious side effect on stable MMI therapy well beyond the typical timeline. Our review of the literature revealed that there really is inconclusive data on the incidence, time, and dose-dependency of MMI-induced agranulocytosis in the pediatric Graves’ disease population.
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Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343-1421. [PMID: 27521067 DOI: 10.1089/thy.2016.0229] [Citation(s) in RCA: 1315] [Impact Index Per Article: 164.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition. METHODS The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. RESULTS Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded. CONCLUSIONS One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.
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Affiliation(s)
- Douglas S Ross
- 1 Massachusetts General Hospital , Boston, Massachusetts
| | - Henry B Burch
- 2 Endocrinology - Metabolic Service, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - David S Cooper
- 3 Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | | | - Peter Laurberg
- 5 Departments of Clinical Medicine and Endocrinology, Aalborg University and Aalborg University Hospital , Aalborg, Denmark
| | - Ana Luiza Maia
- 6 Thyroid Section, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul , Porto Alegre, Brazil
| | - Scott A Rivkees
- 7 Pediatrics - Chairman's Office, University of Florida College of Medicine , Gainesville, Florida
| | - Mary Samuels
- 8 Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University , Portland, Oregon
| | - Julie Ann Sosa
- 9 Section of Endocrine Surgery, Duke University School of Medicine , Durham, North Carolina
| | - Marius N Stan
- 10 Division of Endocrinology, Mayo Clinic , Rochester, Minnesota
| | - Martin A Walter
- 11 Institute of Nuclear Medicine, University Hospital Bern , Switzerland
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Havgaard Kjær R, Smedegård Andersen M, Hansen D. Increasing Incidence of Juvenile Thyrotoxicosis in Denmark: A Nationwide Study, 1998-2012. Horm Res Paediatr 2016; 84:102-7. [PMID: 26111962 DOI: 10.1159/000430985] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 04/27/2015] [Indexed: 11/19/2022] Open
Abstract
AIM The aim of this study was to determine in a Danish nationwide study whether the incidence rate (IR) of thyrotoxicosis in children below 15 years of age has increased between 1998 and 2012 and to compare the results with previously published national data from 1982 to 1988. Furthermore, we intended to conduct a descriptive study of children diagnosed with Graves' disease (GD) between 2008 and 2012. METHODS Children diagnosed with thyrotoxicosis between 1998 and 2012 were identified through the Danish National Patient Registry. All medical records were reviewed to verify the diagnosis. Additional data were collected on children diagnosed with GD in 2008-2012. RESULTS In total, 237 patients with juvenile thyrotoxicosis (JT) were identified. The overall IR in 1998-2012 was 1.58/100,000 person-years and has increased significantly from 0.79/100,000 person-years in 1982-1988 (p < 0.001). The IR has continued to increase during the recent 15 years (1.31-1.83/100,000 person-years), with a 12.5% increase with each 5-year time period. The IR increased with age and female sex (p < 0.001). The descriptive study included 79 children with GD, presenting with a wide spectrum of clinical features. Remission occurred in 13.9%. CONCLUSION The IR of JT has increased significantly since 1982-1988 and has continued to increase during the recent 15 years. The overall IR was 1.58/100,000 person-years during 1998-2012.
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Abstract
Pediatric hyperthyroidism can be multifactorial, with Graves' disease (GD) being the most common etiology. Treatment focuses on identification of the cause of the hyperthyroidism and achieving a biochemical cure with symptom resolution. This article highlights the clinical presentation, diagnosis, and treatment of a pediatric patient with GD. [Pediatr Ann. 2016;45(5):e171-e175.].
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Schamp V, Verfaillie C, Bonroy C, Vande Walle J, Raes A, Dehoorne J. Propylthiouracil induced ANCA-associated vasculitis in a 14-year-old girl. Acta Clin Belg 2015; 70:127-9. [PMID: 25937486 DOI: 10.1179/2295333714y.0000000090] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Antineutrophil cytoplasmic antibodies (ANCAs) are the serologic hallmark of ANCA-associated primary small-vessel vasculitides (AAVs), but these antibodies have also been described in other autoimmune diseases such as inflammatory bowel diseases. Furthermore, different drugs are linked to the induction of ANCA, including propylthiouracil (PTU). However progression into clinical overt vasculitis is less common. CASE-DIAGNOSIS/TREATMENT We describe the case of a young girl with Graves' disease presenting with fatigue, fever, episcleritis and arthritis. The unexpected double myeloperoxidase/proteinase 3-ANCA positivity triggered a multidisciplinary diagnostic work-up and resulted in the diagnosis of a clinically overt PTU-induced AAV. After PTU-withdrawal and treatment with high-dose corticosteroids, a favorable clinical and biochemical evolution was obtained. CONCLUSIONS The use of PTU in the management of hyperthyroidism is not considered first-line treatment in Europe and is even less commonly used in children. Nevertheless, pediatricians should be aware of the possibility of PTU-induced AAV, especially in the presence of multiple ANCA reactivities. Therefore, the use of this drug should be weighed carefully in children.
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22
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Kim H, Kim J, Huh R, Cho SY, Jin DK. Elevation of serum creatine kinase during methimazole treatment of Graves disease in a 13-year-old girl and a literature review of similar cases. Ann Pediatr Endocrinol Metab 2015; 20:106-9. [PMID: 26191516 PMCID: PMC4504990 DOI: 10.6065/apem.2015.20.2.106] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 06/18/2015] [Accepted: 06/19/2015] [Indexed: 01/18/2023] Open
Abstract
We report a 13-year-old girl with Graves disease, who showed an increased level of serum creatine kinase (CK) accompanied by myalgia after methimazole (MMI) treatment. This patient developed muscular pain two weeks after MMI administration, along with increased CK levels. The level of thyroid hormone was within the normal range when she showed increased CK levels. After the MMI dose was decreased and levo-thyroxine was added, serum CK levels decreased to normal and the myalgia improved. The pathophysiologic mechanism of this effect has not yet been elucidated. An acute relatively hypothyroid state occurs secondary to antithyroid drug (ATD) administration in chronic hyperthyroidism, which may cause changes in the CK levels. In this report, we present a rare pediatric case, along with a literature review of similar cases. In the initial state of MMI treatment, myalgia should be detected and when it occurs, CK levels should be measured. The clinical strategy of monitoring CK levels with the aim of normalizing thyroid hormones is helpful in case of the development of adverse reactions, such as myalgia, during ATD treatment for Graves disease in children.
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Affiliation(s)
- Hyeseon Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jinsup Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Rimm Huh
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Yoon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Kyu Jin
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Graves' disease is the most common cause of hyperthyroidism in children. Most children and adolescents are treated with anti-thyroid drugs as the initial modality. Studies have used Methimazole, Carbimazole and Propylthiouracil (PTU) either as titration regimes or as block and replacement regimes. The various studies of anti-thyroid drug (ATD) treatment of Graves' disease in pediatric patients differ in terms of the regimes, remission rate, duration of therapy for adequate remission, follow up and adverse effects of ATD. Various studies show that lower thyroid hormone levels, prolonged duration of treatment, lower levels of TSH receptor antibodies, smaller goiter and increased age of child predicted higher chance of remission after ATD. A variable number of patients experience minor and major adverse effects limiting initial and long term treatment with ATD. The adverse effects of various ATD seem to more in children compared to that of adults. In view of liver injury including hepatocellular failure need of liver transplantation associated with PTU, the use has been restricted in children. The rate of persistent remission with ATD following discontinuation is about 30%. Radioactive iodine therapy is gaining more acceptance in older children with Graves's disease in view of the limitations of ATD. For individual patients, risk-benefit ratio of ATD should be weighed against benefits of radioactive iodine therapy and patient preferences.
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Affiliation(s)
- Mathew John
- Department of Endocrinology, Providence Endocrine and Diabetes Specialty Centre, Kerala, India
| | - Rajasree Sundrarajan
- Department of Pediatric Emergency and PICU, Kamakshi Memorial Hospital, Chennai, Tamil Nadu, India
| | - S. Sridhar Gomadam
- Department of Endocrinology, Providence Endocrine and Diabetes Specialty Centre, Kerala, India
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Lee HS, Hwang JS. The treatment of Graves' disease in children and adolescents. Ann Pediatr Endocrinol Metab 2014; 19:122-6. [PMID: 25346915 PMCID: PMC4208256 DOI: 10.6065/apem.2014.19.3.122] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 09/17/2014] [Indexed: 11/20/2022] Open
Abstract
Graves' disease (GD) accounts for 10%-15% of thyroid disorders in children and adolescents. The use of antithyroid drugs as the initial treatment option in GD is well accepted. An average two years remission is achieved in about 30% of children treated with antithyroid drugs. However, the optimal treatment duration and the predictive marker of remission after antithyroid drug therapy are still controversial. Additionally, (131)I therapy and surgery are considered the option for treatment in children and adolescents with GD. We review the treatment options for pediatric GD and the possible determinants of remission and relapse on antithyroid drug treatment in children and adolescents.
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Affiliation(s)
- Hae Sang Lee
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Jin Soon Hwang
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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