Behavioral assessment of children and adolescents with Graves' disease: A prospective study

Pediatric Graves' Disease: Surgical Interventions in a Single Institution - A Comprehensive Case Series

Introduction

Graves' disease (GD) is the most common cause of hyperthyroidism in children and adolescents. Data regarding pediatric GD in Indonesia are limited and pose challenges to diagnosing and treating the patients. In many aspects the clinical presentation of GD in children and adolescents resembles that of the adult population. There are three treatments for pediatric GD: anti-thyroid drugs, radioiodine ablation, and thyroidectomy. Although surgery is gaining acceptance as the definitive first-line treatment for children with GD, several studies examining pediatric populations have shown high complication rates. This study aims to describe a series of pediatric GD cases from a tertiary care center over an eight-year period.

Presentation of Cases

Retrospective data of five patients with hyperthyroidism diagnosed with GD between 2014 and 2022 were reviewed. Clinical presentation, diagnosis, therapies, and short-term postoperative outcomes of GD were analyzed. All five GD patients presented with neck lumps. Low TSH levels and elevated FT4 levels were found in all patients preoperatively. Total thyroidectomy was performed in all patients, while one patient had lymphadenectomy concurrently. Histopathologic examination confirmed a diagnosis of GD in all patients. All patients in this study experienced postoperative complications such as hoarseness, while only three patients had hypocalcemia as a complication.

Discussion

Total thyroidectomy in pediatric patients remains challenging. The euthyroid condition in patient prior to surgery is recommended to avoid the risk of thyroid storm during surgery, but a few studies have revealed that there is no difference in outcomes for hyperthyroid individuals. Close postoperative surveillance for complications of total thyroidectomy is necessary.

Conclusions

Results of this study showed that pediatric GD patients had the same symptoms of hyperthyroidism as adults with all patients complained of neck lumps. Total thyroidectomy is the definitive therapy for GD in pediatrics as well as in adults. The minority of patients will experience transient and benign morbidities, with hoarseness of the voice being the most common transient postoperative morbidity. In performing total thyroidectomy, meticulous surgery and good anatomical recognition are required to avoid postoperative complications. So that, follow-up of post-total thyroidectomy in pediatric GD patients needs to be done.

Psychological aspects of Graves' ophthalmopathy

Purpose

This review aims to discuss the psychological aspects of Graves' ophthalmopathy (GO), estimate the prevalence of depression and anxiety disorders in GO, examine whether these psychiatric disorders are more prevalent in GO than in Graves' disease (GD) without eye disease, and evaluate the main contributors for depression and anxiety in GO.

Methods

A review of the literature.

Results

Both depression and anxiety are associated with GO. The prevalence of depression and anxiety disorders specifically in GO patients was estimated at 18-33% and 26-41%, respectively. The reported prevalence in GD patients ranged from 9% to 70% for depression and from 18% to 88% for anxiety disorders. Significantly higher levels of depression and anxiety were found in GD patients compared with patients with non-autoimmune hyperthyroidism. Conflicting results have been reported regarding the association of antithyroid autoantibodies with depression and anxiety disorders. Serum thyroid hormone levels do not correlate with the severity of depression and anxiety. An improvement of psychiatric symptoms is observed in hyperthyroid patients after treatment of thyrotoxicosis. Moreover, depression and anxiety are significantly related to impaired quality of life (QoL) in GO. Exophthalmos and diplopia were not associated with depression nor anxiety, but orbital decompression and strabismus surgery do seem to improve QoL in GO patients.

Conclusions

The results of this review suggest that altered thyroid hormone levels and autoimmunity are prognostic factors for depression and anxiety in GO. With regard to the visual and disfiguring aspects of GO as contributing factors for depression and anxiety, no decisive conclusions can be made.

A Reversible Etiology of Progressive Motor Decline in a Previously Healthy Child

We describe the clinical presentation and evaluation of a 10-year-old boy who presented to our medical center with years of progressive proximal muscle weakness, muscle atrophy, and weight loss. In addition to a myopathic phenotype, he was found to have tachycardia, tremor, and learning difficulties. Electromyography revealed chronic myopathic changes and laboratory screening was notable for undetectable thyroid stimulating hormone. Follow-up testing revealed elevated thyroid peroxidase antibodies and thyroid stimulating immunoglobulins. Ultrasound examination revealed an enlarged heterogeneous thyroid gland. Four weeks after treatment with atenolol and methimazole, his strength and cognition began to improve. This case highlights the importance of evaluating for potentially reversible toxic-metabolic etiologies in children presenting with any progressive neurologic symptoms.

Examination of quality of life and psychiatric symptoms in childhood Graves' disease

OBJECTIVES

The aim of our study is to examine the emotional, behavioral problems, and psychiatric symptoms of children diagnosed with Graves' disease (GD), to assess their quality of life, and to compare with control group.

METHODS

The research was planned as a cross-sectional study and included 16 patients with GD (13 female and three male) and 29 healthy children for control group (19 female and 10 male). Sociodemographic form, Pediatric Quality of Life Inventory, Revised Child Anxiety and Depression Scale-Child Version (RCADS-CV), Strengths and Difficulties Questionnaire (SDQ), Turgay DSM-IV-Based Child and Adolescent Behavior Disorders Screening and Rating Scale (T-DSM-IV-S), and Affective Reactivity Index scale were applied to the children and their families.

RESULTS

Eighty one percent of GD group (GG) (n=13, mean age 15.1 ± 2.2) and 66 % of control group (CG) (n=19, 14.6 ± 2.2) were girls. No significant difference was found between GG and CG in terms of quality of life, anxiety, and depression scores. GG had higher scores in affective reactivity index, SDQ-P total score, and T-DSM-IV-S total scores (p values 0.039; 0.009; 0.023, respectively). While no significant difference was detected in the T-DSM-IV-S-inattention and hyperactivity scores, significantly higher scores were detected in oppositional defiance and conduct disorder scores (p values 0.172; 0.294; 0.019; 0.027, respectively).

CONCLUSIONS

In children with GD, irritability, oppositional defiant, and conduct disorder symptoms have been detected. Children with these mental health symptoms experience behavioral and emotional difficulties in their daily lives. It is important to follow up children with GD for possible comorbid psychiatric disorders.

Graves' disease as a driver of depression: a mechanistic insight

Graves' disease (GD) is characterized by diffuse enlargement and overactivity of the thyroid gland, which may be accompanied by other physical symptoms. Among them, depression can dramatically damage patients' quality of life, yet its prevalence in GD has not received adequate attention. Some studies have established a strong correlation between GD and increased risk of depression, though the data from current study remains limited. The summary of mechanistic insights regarding GD and depression has underpinned possible pathways by which GD contributes to depression. In this review, we first summarized the clinical evidence that supported the increased prevalence of depression by GD. We then concentrated on the mechanistic findings related to the acceleration of depression in the context of GD, as mounting evidence has indicated that GD promotes the development of depression through various mechanisms, including triggering autoimmune responses, inducing hormonal disorders, and influencing the thyroid-gut-microbiome-brain axis. Finally, we briefly presented potential therapeutic approaches to decreasing the risk of depression among patients with GD.

Clinically practical pharmacometrics computer model to evaluate and personalize pharmacotherapy in pediatric rare diseases: application to Graves' disease

Objectives

Graves' disease (GD) with onset in childhood or adolescence is a rare disease (ORPHA:525731). Current pharmacotherapeutic approaches use antithyroid drugs, such as carbimazole, as monotherapy or in combination with thyroxine hormone substitutes, such as levothyroxine, as block-and-replace therapy to normalize thyroid function and improve patients' quality of life. However, in the context of fluctuating disease activity, especially during puberty, a considerable proportion of pediatric patients with GD is suffering from thyroid hormone concentrations outside the therapeutic reference ranges. Our main goal was to develop a clinically practical pharmacometrics computer model that characterizes and predicts individual disease activity in children with various severity of GD under pharmacotherapy.

Methods

Retrospectively collected clinical data from children and adolescents with GD under up to two years of treatment at four different pediatric hospitals in Switzerland were analyzed. Development of the pharmacometrics computer model is based on the non-linear mixed effects approach accounting for inter-individual variability and incorporating individual patient characteristics. Disease severity groups were defined based on free thyroxine (FT4) measurements at diagnosis.

Results

Data from 44 children with GD (75% female, median age 11 years, 62% receiving monotherapy) were analyzed. FT4 measurements were collected in 13, 15, and 16 pediatric patients with mild, moderate, or severe GD, with a median FT4 at diagnosis of 59.9 pmol/l (IQR 48.4, 76.8), and a total of 494 FT4 measurements during a median follow-up of 1.89 years (IQR 1.69, 1.97). We observed no notable difference between severity groups in terms of patient characteristics, daily carbimazole starting doses, and patient years. The final pharmacometrics computer model was developed based on FT4 measurements and on carbimazole or on carbimazole and levothyroxine doses involving two clinically relevant covariate effects: age at diagnosis and disease severity.

Discussion

We present a tailored pharmacometrics computer model that is able to describe individual FT4 dynamics under both, carbimazole monotherapy and carbimazole/levothyroxine block-and-replace therapy accounting for inter-individual disease progression and treatment response in children and adolescents with GD. Such clinically practical and predictive computer model has the potential to facilitate and enhance personalized pharmacotherapy in pediatric GD, reducing over- and underdosing and avoiding negative short- and long-term consequences. Prospective randomized validation trials are warranted to further validate and fine-tune computer-supported personalized dosing in pediatric GD and other rare pediatric diseases.

Tocilizumab as a Useful Tool for Thyroid Eye Disease in Pediatric Population: A Case Report

Thyroid eye disease (TED) characterizes by inflammation and remodeling of orbital tissues. Although the majority of pediatric TED is mild, some children present progressive and severe disease. The approach to severe disease in this group of patients, especially when noncortico-responsive, is challenging. The purpose of this work was to describe the effective use of tocilizumab as second-line therapy in steroid-resistant pediatric TED. A 13-year-old female with a history of Graves' disease presented with right eye proptosis for at least 8 months associated with mild pain on eye movements and ocular surface complaints. The ophthalmologic evaluation revealed Hertel exophthalmometry readings of 22 mm on the right eye (OD) and 19 mm on the left (OS). The remaining ophthalmic examination was unremarkable. Intravenous methylprednisolone pulses of 500 mg were initiated without any improvement after 4 treatments. Following multidisciplinary team discussion, therapy was switched to monthly tocilizumab injections at 4 mg/kg. Significant reduction of proptosis and resolution of pain and ocular surface complaints were noted immediately after the treatment switch. Exophthalmometry readings after the end of treatment that included 4 tocilizumab injections were 20 mm on OD and 19 mm on OS. No side effects were reported during the entire follow-up. Six months after treatment cessation, the patient remains stable, without any signs of orbitopathy relapse and no ophthalmologic complaints. This is the second case report showing the effectiveness of tocilizumab in pediatric TED and the first one showing its efficacy when steroids fail. Our results support the potential safety and efficacy of this immunosuppressor in children with TED.

Tocilizumab use in pediatric thyroid eye disease: First documented case

PURPOSE

To report the first case of Tocilizumab treatment for progressive pediatric thyroid eye disease (TED) in a 9-year-old female.

OBSERVATIONS

A 9-year-old female with a history of hyperthyroidism for 4 months presented with bilateral proptosis (more in the right eye) associated with retrobulbar pain, tearing, and conjunctival and caruncular redness. The exophthalmometry reading on presentation was 21mm OD and 17 mm OS. The patient was managed with observation and control of hyperthyroidism in the beginning. However, on a subsequent visit 3 months later it was observed that the symptoms and clinical findings were rapidly worsening. The exophthalmometry reading upon subsequent follow-up was 22 OD and 22 OS. After multidisciplinary team (MDT) discussions it was decided to treat the patient with four doses of 8mg/kg Tocilizumab injection on monthly basis. Notable improvement of proptosis and resolution of pain, conjunctival and caruncular redness was observed. The exophthalmometry reading 4 months after treatment was 20 OD and 19 OS.

CONCLUSION AND IMPORTANCE

This case report opens an important gateway for the use of Tocilizumab in progressive TED in pediatric age groups.