Thyroiditis and acquired hypothyroidism

Higher Rates of Certain Autoimmune Diseases in Transgender and Gender Diverse Youth

Purpose

The objective of this study is to determine the prevalence of certain autoimmune diseases in transgender and gender diverse (TGD) youth.

Methods

A multicenter, retrospective analysis was conducted from January 2013 to January 2019 of youth ≤26 years of age with concurrent diagnoses of gender dysphoria (GD) and at least one of the studied autoimmune diseases. Prevalence rates were calculated and compared to previously reported rates. Statistical significance was determined using second generation p-values as pooled estimates of prevalence rates across study sites compared to a range of rates reported in the literature.

Results

During the study period, 128 of 3812 (3.4%) youth evaluated for GD had a concurrent diagnosis of at least one of the studied autoimmune diseases. Three autoimmune diseases had prevalence rates significantly higher than those previously documented in the literature (second generation p-value=0.000): type 1 diabetes mellitus (112.8/10,000, 95% confidence interval [CI]: 83.8-151.8), systemic lupus erythematosus (13.1/10,000, 95% CI: 5.5-31.5), and Graves' disease (12.3/10,000, 95% CI: 4.0-38.4).

Conclusion

There is an increased prevalence of certain autoimmune diseases in youth who identify as TGD presenting for subspecialty care. Limitations such as retrospective study design, selection bias, and reliance on electronic medical records make it difficult to draw wide-reaching conclusions about these findings. This study highlights the need for more research to delineate the impacts of unrecognized or untreated GD on autoimmune disease development and control.

Monitoring and Management of Bardet-Biedl Syndrome: What the Multi-Disciplinary Team Can Do

Bardet – Biedl syndrome is a rare autosomal recessive multisystem non-motile ciliopathy. It has heterogeneous clinical manifestations. It is caused by mutations in 26 genes encoding BBSome proteins, chaperonines, and IFT complex. The main clinical features are: retinal cone-rod dystrophy, central obesity, postaxial polydactyly, cognitive impairment, hypogonadism and genitourinary anomalies, and kidney disease. The onset of clinical manifestations is variable which makes the diagnosis difficult in some patients. Because of the multiple system involvement, a multidisciplinary approach is necessary. The purpose of this review is to provide monitoring and management directions for a better approach to these patients.

Severe Acquired Primary Hypothyroidism in Children and its Influence on Growth: A Retrospective Analysis of 43 Cases

INTRODUCTION

Severe acquired hypothyroidism in childhood is a rare condition, mostly caused by autoimmune thyroiditis. Scarce and inconsistent data based on small patient numbers exist concerning its impact on growth in height.

METHODS

Patient files at a single centre university hospital over 8 years were retrospectively reviewed. We identified 43 patients (mean age 10.6 years, 3.3-15.25, 59% prepubertal, 88% females) in a cohort of children older than 3 years with an initial TSH>30 mIU/l and reduced T4 or fT4; congenital and drug-induced hypothyroidism were excluded.

RESULTS

All patients had signs of autoimmune thyroiditis (93% positive autoantibodies, 95% typical ultrasonography, 63% goiter). Median TSH was 100 mIU/l [0.3-4 mIU/l]), median fT4 3.55 pg/ml [8-19 pg/ml], median T4 2.85 µg/dl [5.3-11 µg/dl]. Presenting symptoms included goiter (26%), tiredness (23%), weight gain (19%), and growth retardation (19%). The diagnosis was made incidentally in 26% patients. In 75% growth was retarded (median height standard deviation score (SDS)-0.55), in 17% height SDS was<-2 at diagnosis. Midparental height SDS at diagnosis correlated significantly with T4 and fT4 (r=0.77, p=0.0012 and r=0.53, p=0.021 respectively). Catch-up growth under T4 substitution was significantly greater in prepubertal than in pubertal children (p 0.049).

CONCLUSION

This so far largest pediatric cohort with severe acquired hypothyroidism confirms a serious impact on growth which, however in most cases, showed a certain catch-up growth after adequate L-thyroxine therapy. The pubertal state seems to be important for catch-up growth. A significant number of patients were not diagnosed clinically, although affected by severe hypothyroidism.

Ultrasound variants of autoimmune thyroiditis in children and adolescents and their clinical implication in relation to papillary thyroid carcinoma development

BACKGROUND

The prevalence of autoimmune thyroiditis (AIT) and papillary thyroid carcinoma (PTC) is rising in children and adolescents, and the coincidence of AIT and PTC is as high as 6.3-43%.

OBJECTIVE

To investigate the ultrasound manifestation of AIT in relation to PTC development in paediatric patients.

PATIENTS

179 paediatric patients (133 females), mean (SD) age: 13.9 (3.03) years diagnosed with AIT and referred for ultrasound evaluation. Eight patients were diagnosed with PTC (6 females).

METHODS

Retrospective analysis of thyroid ultrasound scans of patients diagnosed with AIT. Thyroid and autoimmune status was assessed based on TSH, fT4, fT3 and increased aTPO and/or aTG and/or TRAB levels. In patients with PTC, total thyroidectomy was performed.

RESULTS

Analysis of thyroid US scans revealed that the following five ultrasound variants of AIT were observed in 179 patients: the most common in 35.2%-diffuse thyroiditis with hypoechogenic background and normoechogenic parenchyma, in 30.2%-diffuse thyroiditis with irregular background, in 18.9% nodular variant with normoechogenic background, in 11.7%-micronodulations and in 3.9%-diffuse hypoechogenic background. Eight cases of PTC were diagnosed in nodular variant of AIT with normoechogenic irregular background.

CONCLUSION

Patients with AIT and nodular variant with normoechogenic irregular background of the thyroid gland on US scans are in the risk group of developing PTC and should be followed up with regular neck US assessment.

Pediatric Hypothyroidism: Diagnosis and Treatment

Thyroid hormone has important physiologic functions in nearly every organ system. The critical role of thyroid hormone in growth and in physical and neurologic development lends particular importance to the prompt diagnosis and appropriate treatment of hypothyroidism in infants and children. Congenital hypothyroidism is common and has potentially devastating neurologic consequences. While the approach to diagnosis and treatment of severe congenital hypothyroidism is well established, data continue to emerge about the genetic causes, clinical significance, and prognosis of the milder forms of congenital hypothyroidism that are increasingly being diagnosed by newborn screening. Similarly, the diagnosis and treatment of severe acquired hypothyroidism is straightforward and clearly of clinical benefit, but uncertainty remains about the optimal management of mild subclinical hypothyroidism. This review summarizes current knowledge of the causes, clinical manifestations, diagnosis, treatment, and prognosis of hypothyroidism in infants and children, with a focus on recent developments and areas of uncertainty in this field.

Atopy and autoimmune thyroid diseases: melatonin can be useful?

Recently, there has been growing interest in the relationship between allergic and autoimmune diseases. Allergy and autoimmunity can be considered two potential outcomes of dysregulated immunity and analysis of literature data shows a strong positive association between a history of Th2-mediated allergic disorders and Th1-mediated autoimmune disorders.

Autoimmune thyroid diseases are the most common of all autoimmune pathological conditions.

Currently, the mechanisms explaining an association among atopy, autoimmunity, and thyroid diseases are not fully understood.

There are data in literature pointing to the relationship between melatonin and thyroid activity. Several studies have suggested a paracrine role for this molecule in the regulation of thyroid activity, documenting that administration, as an antioxidant, in thyroid tissues under conditions of increased oxidative stress, could be helpful to reduce the oxidative processes involved in autoimmune thyroid diseases.

Although thyroid autoimmunity has been regularly associated with atopic conditions in children, the possible protective role of melatonin has not yet been investigated.

This review summarizes what is known regarding the connection between atopy and autoimmune thyroid diseases, and analyses the probable beneficial action of melatonin.

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.

Rare cases of autoimmune hypothyroidism in young children

Acquired autoimmune hypothyroidism is common in late childhood and adolescence but is very rare in the first 3 years of life. We report on three cases of autoimmune thyroiditis (AT) in young children who presented with constipation, decreased appetite, and increased hours of sleep. Our cases highlight that AT may remain undiagnosed for a long time in young children owing to the rarity of the disease.

Simulation of post-thyroidectomy treatment alternatives for triiodothyronine or thyroxine replacement in pediatric thyroid cancer patients

BACKGROUND

As in adults, thyroidectomy in pediatric patients with differentiated thyroid cancer is often followed by (131)I remnant ablation. A standard protocol is to give normalizing oral thyroxine (T(4)) or triiodothyronine (T(3)) after surgery and then withdraw it for 2 to 6 weeks. Thyroid remnants or metastases are treated most effectively when serum thyrotropin (TSH) is high, but prolonged withdrawals should be avoided to minimize hypothyroid morbidity.

METHODS

A published feedback control system model of adult human thyroid hormone regulation was modified for children using pediatric T(4) kinetic data. The child model was developed from data for patients ranging from 3 to 9 years old. We simulated a range of T(4) and T(3) replacement protocols for children, exploring alternative regimens for minimizing the withdrawal period, while maintaining normal or suppressed TSH during replacement. The results are presented with the intent of providing a quantitative basis to guide further studies of pediatric treatment options. Replacement was simulated for up to 3 weeks post-thyroidectomy, followed by various withdrawal periods. T(4) vs. T(3) replacement, remnant size, dose size, and dose frequency were tested for effects on the time for TSH to reach 25 mU/L (withdrawal period).

RESULTS

For both T(3) and T(4) replacement, higher doses were associated with longer withdrawal periods. T(3) replacement yielded shorter withdrawal periods than T(4) replacement (up to 3.5 days versus 7-10 days). Higher than normal serum T(3) concentrations were required to normalize or suppress TSH during T(3) monotherapy, but not T(4) monotherapy. Larger remnant sizes resulted in longer withdrawal periods if T(4) replacement was used, but had little effect for T(3) replacement.

CONCLUSIONS

T(3) replacement yielded withdrawal periods about half those for T(4) replacement. Higher than normal hormone levels under T(3) monotherapy can be partially alleviated by more frequent, smaller doses (e.g., twice a day). LT(4) may be the preferred option for most children, given the convenience of single daily dosing and familiarity of pediatric endocrinologists with its administration. Remnant effects on withdrawal period highlight the importance of minimizing remnant size.

Diagnostic approach to goitre in children

Thyroid disease is a common paediatric disorder that affects up to 3.7% of school-aged children, and it usually presents with a goitre. By far, the most frequent cause of a goitre is autoimmune thyroid disease, although a benign colloid goitre is also a common cause. The present review focuses on the diagnostic approach to a child with a hypothyroid, hyperthyroid or euthyroid goitre.

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 thyroid diseases in children

The two major autoimmune thyroid diseases (ATDs) include Graves' disease (GD) and autoimmune thyroiditis (AT); both of which are characterized by infiltration of the thyroid by T and B cells reactive to thyroid antigens, by the production of thyroid autoantibodies and by abnormal thyroid function (hyperthyroidism in GD and hypothyroidism in AT). While the exact etiology of thyroid autoimmunity is not known, it is believed to develop when a combination of genetic susceptibility and environmental encounters leads to breakdown of tolerance. It is important to recognize thyroid dysfunction at an early stage by maintaining an appropriate index of suspicion.

Neonatal autoimmune hypothyroidism: a patient report

BACKGROUND

Acquired primary hypothyroidism in neonates and infants under 3 years of age is very rare. Herein we report the case of an infant female affected by acquired autoimmune hypothyroidism.

PATIENT REPORT

The infant was transferred to the Pediatric Clinic, University of Catania, Italy for evaluation of dysmorphic features, growth and motor retardation, and hypothyroidism on laboratory testing. Neonatal screening test for TSH and PKU was negative. An ultrasound scan showed a non-homogeneous thyroid gland which was increased in volume. Based on the laboratory results, the diagnosis of autoimmune hypothyroidism was made and L-thyroxine treatment was initiated at 50 microg/day.

CONCLUSIONS

Autoimmune hypothyroidism in infancy is rare, but early recognition and therapy are essential to prevent neurologic damage and growth deficits. In this patient we would like to underline the early age of appearance of autoimmune thyroid disease and the possible onset of pathologic events before birth.

Unusual clinical presentation of primary hypothyroidism in a very young infant caused by autoimmune thyroiditis: case report and update of the literature

Acquired primary hypothyroidism in infancy can be related to autoimmune thyroiditis and can present with unusual symptoms, such as muscle pseudohypertrophy and pituitary tumor. This condition can cause permanent deficits in psychomotor development and growth despite adequate replacement with L: -thyroxine.

[Evidences for subclinic chronic autoimmune thyroid disease in girls with Turner Syndrome]

Patients with Turner syndrome (TS) frequently exhibit transient, recurrent and asymptomatic variations of TSH and/or thyroid hormones (TH). This work was carried out to evaluate thyroid function and structure in patients with TS who had had such variations in hormone concentrations. Our sample comprised 24 patients, 17 less than 20-years old. Evaluation included serum levels of TSH, free T4, total T3, TPO and Tg autoantibodies, thyroid ultrasound (US) and scintigraphy with 99mTc-pertechnetate. Thirteen patients had abnormal TSH and/or TH levels; 23 exhibited US features compatible with chronic thyroid disorder, particularly thyromegaly (established according to volume expected for stature) and heterogeneous echogenicity. Uptake was normal in 21 cases and tracer distribution was homogeneous in 22. The finding of abnormal hormone concentrations was independent of age, length of time since the first similar finding, thyroid autoantibodies, number of abnormalities at US and abnormal scintigraphic findings. Patients aged more than 20 years had higher frequency of thyroid antibodies and heterogeneous echogenicity, and thyroid volume was significantly correlated to length of time since detection of the first hormone variation, indicating progressive thyroid disease. These results suggest that subclinical thyroid dysfunction in TS is due to chronic autoimmune thyroid disease.

The treatment of Graves' disease in children

Graves' disease is the most common form of hyperthyroidism in childhood. Current treatment options include antithyroid medications, surgery, and radioactive iodine. Medical therapy is generally associated with long-term remission rates of less than 25% and a small risk of serious adverse reactions that include hepatic failure and bone marrow suppression. Total thyroidectomy is associated with very high cure rates and a small risk of hypoparathyroidism and recurrent laryngeal nerve damage. When radioactive iodine is used at appropriate doses, there is a very high cure rate without increased risks of thyroid cancer or genetic damage. Clinicians caring for the child or adolescent with Graves' disease are thus faced with using medications with potential short-term and long-term toxicity, for a condition in which spontaneous remission occurs in the minority of pediatric patients. Definitive therapy in the form of surgery or radioactive iodine is necessary and unavoidable for the majority of pediatric patients with Graves' disease.

Severe hypothyroidism due to atrophic thyroiditis from second year of life influenced developmental outcome

From the second year of life a girl showed an insidious development of clinical hypothyroidism due to a non-goitrous lymphocytic thyroiditis without traceable circulating levels of thyroid antibodies measured by routine immunoassays. The diagnostic delay of this rare variant of atrophic thyroiditis caused persistent neuropsychological deficits.

CONCLUSION

Her difficulties with speed of processing and working memory in particular could suggest a frontal deficit, possibly in the dorsolateral prefrontal circuit. This contrasts with findings in congenital hypothyroidism, suggesting a relatively preserved frontal function, and could illustrate different neuropsychological deficits of hypothyroidism at different ages in early childhood.

Hashitoxicosis in children: clinical features and natural history

OBJECTIVE

To determine the incidence, natural history, and clinical characteristics of Hashitoxicosis (Htx) in pediatric patients with autoimmune thyroiditis.

STUDY DESIGN

Medical records of children diagnosed with Hashimoto thyroiditis between 1993 and 2002 were reviewed. The clinical course of patients presenting with hyperthyroidism was determined. Variables including sex, age, family history, thyroid hormone levels, anti-thyroid antibody titers, 123 I thyroid scan results, and presenting features were investigated as possible predisposing factors for the development of Htx.

RESULTS

Out of 69 patients with autoimmune thyroiditis, 8 were diagnosed with Htx. The duration of hyperthyroidism ranged from 31 to 168 days. Three patients became hypothyroid after an average of 46.3 +/- 13.2 days, and 5 patients became euthyroid after an average of 112.8 +/- 59.8 days. Additional findings included an elevated thyroid stimulating immunoglobulin (TSI) titer in 3 of the 8 patients with Htx, and increased uptake on 123 I scan in 2 patients.

CONCLUSION

Htx is an uncommon yet important cause of hyperthyroidism in children that has a variable clinical course. The diagnosis may be complicated, as presenting features sometimes exhibit significant overlap with Graves' disease. No factors predisposing to the development of Htx were identified.

Catch-up growth in severe juvenile hypothyroidism: treatment with a GnRH analog

Anecdotal reports suggest that the addition of a gonadotropin releasing hormone (GnRH) analog (GnRHa) in addition to L-thyroxine (LT4) replacement may increase adult stature in children with severe longstanding hypothyroidism by prolonging the pubertal growth period. This retrospective chart review compares the height outcome and body mass index in 33 children (21 treated with LT4 alone and 12 treated with LT4 + GnRHa) with severe longstanding hypothyroidism and bone age delay. Seventeen controls and six GnRHa-treated patients were followed to adult height (BA >14 yr [F]/16 yr [M] and/or growth velocity < 2 cm/yr). At diagnosis, GnRHa-treated patients were 1) older and shorter for chronological age, and 2) more advanced in puberty and bone age. Despite these differences, at adult height, both groups had similar improvements in height Z scores, similar height deficits, and comparable adult heights. Changes in BMI Z score were similar for both groups. Our study suggests that the addition of GnRHa to LT4 may improve interval growth without imposing a risk of obesity in children with longstanding severe hypothyroidism.

Tireoidite de Hashimoto na Infância e na Adolescência: Estudo Retrospectivo de 43 Casos

A tireoidite de Hashimoto (TH) é uma doença auto-imune considerada a principal causa de bócio e hipotireoidismo adquirido em crianças e adolescentes em áreas não endêmicas. Este estudo avaliou retrospectivamente 43 pacientes entre 1,1 e 17,6 anos com TH, 36 do sexo feminino e 7 do sexo masculino (proporção 5:1). Destes, 81% apresentavam bócio. Na avaliação inicial 37% dos pacientes eram eutireóideos (n=16), 28% apresentavam hipotireoidismo compensado (n=12), 26% hipotireoidismo descompensado (n=11) e 9% eram hipertireóideos (n=4). Anticorpo anti-tireoperoxidase esteve positivo em 75% dos casos e anti-tireoglobulina em 68%. Todos os pacientes com hipotireoidismo foram tratados com reposição de tiroxina. Apenas 3 pacientes entraram em remissão após o término da puberdade sugerindo que a evolução para remissão deve ser considerada e avaliada também após esta fase e periodicamente.

Demystifying autoimmune thyroid disease. Which disorders require treatment?

The term "autoimmune thyroid disease" encompasses all of the autoimmune thyroid conditions, including Hashimoto's thyroiditis, Graves' disease, most cases of silent thyroiditis, and postpartum thyroiditis. Extrathyroidal manifestations (e.g., ophthalmopathy, dermopathy) can occur in Graves' disease and, less commonly, Hashimoto's thyroiditis. Spontaneous hypothyroidism is common in patients with Hashimoto's thyroiditis, and when it develops, life-long therapy with levothyroxine is needed. In the United States, most adult patients with Graves' disease are initially or eventually treated with radioiodine thyroid ablation. For transient thyroiditis involving hypothyroidism or hyperthyroidism, short-term or symptomatic therapy is adequate.

Common childhood thyroid disorders

This article presents current knowledge about common childhood thyroid gland disorders. Included are congenital and acquired hypothyroidism, hyperthyroidism, disorders due to iodine deficiency, tumors and miscellaneous conditions. The significance of early diagnosis by screening and institution of treatment of congenital hypothyroidism is emphasized. Etiology, pathogenesis, clinical signs and symptoms, diagnosis and treatment are discussed.