Thyroid-associated ophthalmopathy in juvenile Graves' disease--clinical, endocrine and therapeutic aspects

Successful Case of Teprotumumab Treatment in an Adolescent Patient With Thyroid Eye Disease

A 16-year-old black female presented with a 4-month history of significant proptosis and diplopia in the setting of diagnosed Graves disease. The patient underwent 8 infusions of teprotumumab. She had migraines and diplopia that were resolved with treatment. There was also a dramatic improvement in her proptosis. The authors present the first reported case of successful teprotumumab treatment in an adolescent patient, describing outcomes and proposing a mechanism for her transient side effects.

Treating Thyroid Associated Ophthalmopathy in Pediatric Patients

Thyroid associated ophthalmopathy (TAO) is a common extra-thyroid clinical manifestation of Graves' disease. It is an inflammatory disease of the eye and orbital tissues. Up to one-third of pediatric Graves' disease patients could be diagnosed with TAO. The symptoms can be variable with remissions and exacerbations of pediatric Graves' disease, which has negative effects on the quality of life in children. Teprotumumab is a fully human IgG1κ type monoclonal antibody targeting insulin-like growth factor-1 receptor (IGF-1R), and was approved for the treatment of TAO as a "breakthrough therapy" by the FDA in 2020. Nevertheless, the safety and effectiveness have not been established in pediatric patients. IGF-1R plays an important role in human development, which raises concerns of developmental toxicity. As presented in the pharmacology review report, juvenile monkeys were tested in two separate repeated-dose toxicity studies and no NOAEL was identified. Teprotumumab affected the growth, thymus, spleen and decreased the bone growth. Younger animals seemed to be more sensitive to the effects on normal growth and normal thymus. Hearing impairment posed additional risk to the potential pediatric use, especially for school-age children. Considering the nature of the target, Teprotumumab should not be used empirically in children. More efforts would be made for the further development of teprotumumab for pediatric use.

A retrospective study of pediatric thyroid eye disease: the Asian experience

AIM

To study the clinical presentation, disease characteristics, and management approach for children with thyroid eye disease (TED) over a 10 year period in a multidisciplinary Paediatric Thyroid Eye Disease Clinic at a tertiary care referral center.

METHODS

Retrospective case series of patients with TED at Kandang Kerbau Women's and Children's Hospital (KKWCH) Singapore between August 2006 to June 2015. The diagnosis of TED was clinical based on the Bartley criteria. Ophthalmic examination findings, systemic thyroid function and ophthalmological intervention were recorded.

RESULTS

Nineteen subjects with pediatric TED were studied. The median age at diagnosis was 12.5 years (range 6-17). The onset of TED was at the same time as their thyroid disease in half of these patients (52.6%) of which all were hyperthyroid except one. The most common signs at TED diagnosis were proptosis (84.2%), lid retraction (63.2%), acquired epiblepharon (63.2%). All patients were inactive and none had evidence of compressive optic neuropathy. TED remained stable in all patients except for one who developed worsening proptosis with exposure keratopathy. No patients were prescribed steroids (oral or intravenous) or had orbital decompression surgery. The most debilitating morbidity was acquired epiblepharon of which out of 12 patients, one had everting sutures and three were offered surgical correction.

CONCLUSIONS

Paediatric TED subjects exhibit milder clinical manifestations compared to adults. Acquired epiblepharon causes most significant visual morbidity by compromising the corneal surface. Being cognizant of the subtleties of pediatric TED will permit the discerning clinician to effectively manage such cases accordingly.

Sirolimus (rapamycin) for the targeted treatment of the fibrotic sequelae of Graves' orbitopathy

BACKGROUND

Rapamycin (alternatively known as sirolimus) is a macrolide immunosuppressant commonly used for organ transplantation. It acts both on lymphocytes through the mechanistic target of rapamycin (mTOR) pathway to reduce their sensitivity to interleukin-2 (IL-2) and, importantly, also has anti-fibrotic properties by acting on myofibroblasts. The latter have been implicated in the pathogenesis of thyroid eye disease (TED).

AIM

To describe successful treatment and reversal of extraocular muscle fibrosis in TED with sirolimus.

METHODS

Case report and literature review with clinic-pathological correlation.

RESULTS

A patient with Graves' orbitopathy (GO) developed significant ocular motility restriction, which was unresponsive to steroids and conventional immunosuppression. Unlike these prior treatments, rapamycin therapy improved the diplopia and fields of binocular single vision over a period of months. There were no adverse effects directly attributable to the treatment.

CONCLUSION

With its low renal toxicity and ability to specifically target the underlying fibrotic pathways in GO, rapamycin may prove a useful adjunct to standard immunosuppressive regimes. We encourage further reporting of case series or the instigation of controlled trial.

Corticosteroids in Moderate-To-Severe Graves' Ophthalmopathy: Oral or Intravenous Therapy?

Background: Ophthalmopathy is a rare extra-thyroid manifestation of Graves’ disease, in paediatrics. Intravenous corticosteroids are the main treatment of moderate-to-severe Graves’ orbitopathy. In this paper, we describe a moderate-to-severe active Graves’ ophthalmopathy in a child and the response to oral therapy with prednisone. Case presentation: A nine-year-old male child suffering for a few months, from palpitations, tremors, and paresthesia was hospitalized in our Pediatric Clinic. At admission, the thyroid function laboratory tests showed hyperthyroidism with elevated free thyroxine (FT4) and free triiodothyronine (FT3) levels and suppressed thyroid-stimulating hormone (TSH) levels. These findings, combined with the clinical conditions—an ophthalmologic evaluation (that showed the presence of exophthalmos without lagophthalmos and visual acuity deficiency), thyroid ultrasound, and TSH receptor antibody positivity—led to a diagnosis of Graves’ disease. Therefore, methimazole was administered at a dose of 0.4 mg/kg/day. After 4 months, thyroid function was clearly improved, with normal FT3 and FT4 values and increasing TSH values, without adverse effects. Nevertheless, an eye examination showed ophthalmopathy with signs of activity, an increase in the exophthalmos of the right eye with palpebral retraction, soft tissue involvement (succulent and oedematous eyelids, caruncle and conjunctival hyperaemia and oedema) and keratopathy, resulting from exposure. We began steroid therapy with oral administration of prednisone (1 mg/kg/day) for four weeks, followed by gradual tapering. After one week of therapy with prednisone, an eye assessment showed reduced retraction of the upper eyelid of the right eye, improvement of right eye exophthalmometry and reduction of conjunctival hyperaemia. After four weeks of therapy with prednisone, an eye assessment showed reduction of the right palpebral retraction without conjunctival hyperaemia and no other signs of inflammation of the anterior segment; after twelve weeks, an eye assessment showed a notable decrease in the right palpebral retraction and the absence of keratitis, despite persisting moderate conjunctival hyperaemia. No adverse event associated with steroid use was observed during the treatment period and no problem in compliance was reported. Conclusion: Prednisone seems a better choice than intravenous corticosteroids, for treating moderate-to-severe and active Graves’ ophthalmopathy, keeping in mind the importance of quality of life in pediatric patients.

The Influence of Juvenile Graves' Ophthalmopathy on Graves' Disease Course

Purpose

To investigate juvenile Graves' ophthalmopathy (GO) signs and compare Graves' disease (GD) course in patients with or without GO.

Patients and Methods

There were analyzed data (visual acuity, proptosis, palpebral fissure measurements, clinical activity score (CAS), and the course of GD) of 67 children who have been newly diagnosed with GD. 26.9% of patients with GD had signs of ophthalmopathy (GO+), and 73.1% were without ophthalmopathy (GO−).

Results

Upper eyelid retraction (72.3%), proptosis (66.7%), and soft tissue changes (27.8−38.9%) were in GO+ patients. The palpebral fissure, CAS, and proptosis values were greater in the GO+ group than in the GO− group (p < 0.001). GD course in GO+ patients was longer than that in GO− patients (p < 0.001). The duration of the first remission was longer in GO− than in GO+ patients (p < 0.001). The duration of first remission was longer than one year for 61.2% in GO− and 33.3% in GO+ patients (p < 0.02).

Conclusion

The common manifestations of juvenile GO patients were upper eyelid retraction, proptosis, and soft tissue involvement. The study demonstrates that pediatric patients with GO are more likely to have a severe course of autoimmune thyroid disease.

Predictive Factors of Development of Graves' Ophthalmopathy for Patients with Juvenile Graves' Disease

Background. Due to low incidence of Graves' ophthalmopathy (GO) among children, the manifestation is poorly analyzed, posing a risk to late identification of insidious disease. Purposes. To identify predictive factors that may influence the development of GO in pediatric and young patients with Graves' disease (GD). Methods. A cross-sectional study of patients newly diagnosed with pediatric or juvenile GD during 2002-2012 was conducted at the Hospital of Lithuanian University of Health Sciences. Ocular evaluation was based on European Group on Graves' Orbitopathy survey. The ocular manifestations were analyzed in relation to demographic, environmental, and clinical factors. Results. In total, 130 patients with juvenile GD were included; 29.2% had GO. Median age at GD onset was 17 yrs (IQR 4-29). Main symptoms of GO were eyelids retraction (73.7%), proptosis (65.8%), injection of conjunctiva (42.1%), and eyeball motility disturbance (21.1%). Major significant and independent risk factors for GO development were high initial concentration of FT4 (OR = 5.963), TTHAb (OR = 6.358), stress (OR = 6.030), and smoking (OR = 7.098). Conclusion. The major factors that could influence GO development were smoking, stress, and increased levels of initial TRAb, FT4. Slight proptosis, retraction of eyelids, and conjunctive injection were found as predominant ophthalmological symptoms in juvenile GO.

Clinical relevance of thyroid-stimulating autoantibodies in pediatric graves' disease-a multicenter study

CONTEXT AND OBJECTIVE

The incidence of TSH receptor (TSHR) stimulating autoantibodies (TSAbs) in pediatric Graves' disease (GD) is controversial. This large, multicenter study evaluated the clinical relevance of TSAbs in children with GD both with Graves' orbitopathy (GO) and without orbital disease.

DESIGN

We conducted a cross-sectional retrospective study.

SETTING

Sera were collected in seven American and European academic referral centers and evaluated in a central laboratory. PATIENTS AND SAMPLES: A total of 422 serum samples from 157 children with GD, 101 control individuals with other thyroid and nonthyroid autoimmune diseases, and 50 healthy children were studied.

MAIN OUTCOME MEASURES

TSAbs were measured using a novel, chimeric TSHR bioassay and a cAMP response element-dependent luciferase. TSH binding-inhibitory Ig (TBII) and parameters of thyroid function were also determined.

RESULTS

In 82 untreated children with GD, sensitivity, specificity, and positive and negative predictive values for TSAb and TBII were: 100 and 92.68% (P = .031), 100 and 100%, 100 and 100%, and 100 and 96.15%, respectively. TSAb and TBII were present in 147 (94%) and 138 (87.9%) of the 157 children with GD (P < .039), respectively; and in 247 (94%) and 233 (89%) of the 263 samples from this group (P < .0075), respectively. In children with GD and GO, TSAb and TBII were noted in 100 and 96% (P < .001), respectively. Hyperthyroid children with GD and GO showed markedly higher TSAb levels compared to those with thyroidal GD only (P < .0001). No significant differences were noted for TBII between the two groups. After a 3-year (median) medical treatment, the decrease of TSAb levels was 69% in GD vs 20% in GD and GO (P < .001). All 31 samples of euthyroid children with GO were TSAb positive; in contrast, only 24 were TBII positive (P = .016). All children with Hashimoto's thyroiditis, nonautoimmune hyperthyroidism, type 1 diabetes, and juvenile arthritis and the healthy controls were TSAb and TBII negative.

CONCLUSIONS

Serum TSAb level is a sensitive, specific, and reproducible biomarker for pediatric GD and correlates well with disease severity and extrathyroidal manifestations.

Thyroid peroxidase antibody positivity and triiodothyronine levels are associated with pediatric Graves' ophthalmopathy

BACKGROUND

Graves' ophthalmopathy (GO) occurs commonly in children with Graves' disease (GD). However, there are limited studies on the clinical manifestations and thyroid autoantibodies in pediatric GO. The aim of this study was to investigate the prevalence and risk factors of GO in childhood GD.

METHODS

Clinical and biochemical data from children and adolescents with GD were retrospectively reviewed. Eighty patients under 19 years of age were included in the present study. We compared the clinical and biochemical differences between patients with and without GO.

RESULTS

Thirty-nine percent of the patients had GO, and 81% of the GO patients were females. Of these, two patients showed unilateral GO. Triiodothyronine (T3) levels were higher in GO patients than in those without GO. Anti-thyroglobulin antibody and thyroid stimulating hormone receptor antibody titers were not significantly different between the two groups. Anti-thyroid peroxidase antibody (TPO Ab) positivity was 68% in the patients with GO and only 47% in the patients without GO. In multivariate regression analysis, high T3 levels and TPO Ab positivity were related to the presence of GO.

CONCLUSION

In children and adolescents with GD, TPO Ab positivity and high T3 levels could act as predictive factors for the presence of GO.

Immunotherapy in miscellaneous medical disorders Graves ophthalmopathy, asthma, and regional painful syndrome

In Graves ophthalmopathy, immunotherapy is offering an opportunity of reducing bad outcomes that lead to disfigurement and impairment of vision. These therapies are not perfect; however, we now have a chance to achieve better outcomes. In asthma, immune therapy using passive immunity targeting key proinflammatory cytokine/chemokines and medications of their effects has opened an avenue of research into a safe and durable therapy. Omalizumab appears to be safe and effective in clinical use. In regional pain syndrome, immune mechanisms may be involved in sustaining long-standing pain, and IVIG may moderate pain sensitivity by reducing immune activation.

[Thyroid ophthalmopathy at the time of European Group On Graves Orbitopathy (EUGOGO)]

Thyroid ophthalmopathy is one of the features of auto-immune thyroid diseases. Exophtalmos is not the only sign of this affection and may even be absent in severe sight-threatening cases. All subjects with this ophtalmopathy should benefit from euthyroidism restoration, smoking withdrawal and local measures. Objective and repeated assessment should identify the mild and stable disease carrying a fair prognosis and therefore recognize without delay the other patients for whom an optimal management will be supported by a multidisciplinary and expert team. The treatment of choice for moderate-to-severe and active ophthalmopathy is intravenous glucocorticoids. Sight-threatening cases not rapidly alleviated by intravenous glucocorticoids warrant surgical decompression. Later on, surgery (orbital decompression, squint surgery, eyelid surgery, in this order) will eventually be needed for inactive disease.

Pediatric thyroid-associated orbitopathy: the Children's Hospital of Philadelphia experience and literature review

BACKGROUND

As Graves' disease is uncommon in children, Graves' eye disease should be even more unusual. Here we report our experience with Graves' eye disease at the Children's Hospital of Philadelphia and review the literature on ophthalmic findings in children with Graves' disease.

SUMMARY

A retrospective review identified 152 children with Graves' disease seen in the endocrinology clinic of the Children's Hospital of Philadelphia over a 3-year period. Of this cohort, only 26 (17%) were referred to ophthalmology because of prominent ophthalmic manifestations. The ages of the patients ranged from 4 months to 17 years. Sixteen of 26 patients were female. Most patients had mild findings consistent with Graves' disease. Proptosis was noted in 10 of 26 (38%). Lid retraction was present in 6 of 26 (23%). Mild corneal punctuate staining was identified in only 3 of the 26 patients (12%). No patients had strabismus or optic neuropathy. Three newly diagnosed Graves' patients who were seen as the retrospective review was being completed were all girls. All three had normal vision, motility, and fundus exams. Two had mild proptosis, lid retraction, and lid lag on down gaze. None had corneal, motility, or optic nerve pathology. These findings are consistent with previous studies in the literature.

CONCLUSIONS

Eye findings in pediatric Graves' disease are usually mild and typically respond to local measures and control of disturbed thyroid function. Surgery is indicated in a small number of patients for cornea exposure or appearance issues. Graves' disease-associated optic neuropathy has never been reported in the pediatric population.