Update on Pediatric Hyperthyroidism

Neonatal graves' disease complicated with cholestatic jaundice: a case report

BACKGROUND

Neonatal cholestatic jaundice and elevated liver enzymes can result from various etiologies, including anatomical, infectious, endocrine, and metabolic abnormalities. Unlike hypothyroidism, hyperthyroidism is rarely associated with neonatal cholestasis. This study presents a unique case of neonatal Graves' disease complicated by cholestatic jaundice and discusses the challenges in diagnosis, treatment, and management.

CASE PRESENTATION

We report a 30-day-old male infant, born by vaginal delivery at 36.4 weeks gestational age, born weight was 2550 g, to a mother with a history of hypothyroidism during pregnancy, undiagnosed thyroid disease before. The infant developed manifestations of hyperthyroidism, poor weight gain, and cholestatic jaundice shortly after his inception. A variety of tests were used to confirm the diagnosis of neonatal Graves' disease. After 6 weeks of propylthiouracil and hepatoprotective choleretic therapy, thyroid-thyrotropic hormonal metabolism returned to normal, cholestatic jaundice disappeared after 2 months, and liver enzymes returned to normal after 3 months. In addition, the child's weight and length growth returned to the normal range during the follow-up period.

CONCLUSIONS

Neonatal Graves' disease can be associated with cholestatic jaundice and may have long-term health consequences for the newborn. Early diagnosis and appropriate treatment are crucial for improving the prognosis. This case emphasizes the importance of monitoring pregnant women for thyroid dysfunction and its potential impact on the newborn.

Treatment Challenges of Methimazole-Induced Agranulocytosis in Younger Patients

Introduction: Methimazole is considered the first-line antithyroid drug for Graves’ disease (GD) in children and adolescents. However, it can lead to severe adverse effects, such as agranulocytosis, which can result from direct drug toxicity or immune-mediated responses. This report aims to describe the clinical management of an adolescent with GD who developed agranulocytosis following methimazole administration. Case Presentation: A 13-year-old female, diagnosed with GD, developed neutropenia six months after starting methimazole. She was admitted with high-grade fever, sore throat, palpitations, fatigue, myalgia, and diarrhea. The treatment regimen included filgrastim, antibiotics, β-blockers, a solution of potassium iodide (SSKI), cholestyramine, and lithium. Within seven days, her absolute neutrophil count gradually improved, her fever subsided, her hyperthyroidism was controlled, and she was discharged. Discussion: Antithyroid drug-induced neutropenia represents a serious complication. In these patients, effective infection management, control of hyperthyroidism, and supportive measures to promptly increase the neutrophil count can reduce the associated morbidity and mortality. Conclusions: Close monitoring and awareness of risk factors, such as age, female sex, and higher doses of methimazole, may decrease the risk of agranulocytosis and its fatal outcomes. Alternative treatments to control hyperthyroidism during methimazole-induced agranulocytosis include β-blockade, potassium iodide solution (SSKI), cholestyramine, steroids, and lithium.

Transcriptomic and proteomic investigations identify PI3K-akt pathway targets for hyperthyroidism management in rats via polar iridoids from radix Scrophularia

High-polarity iridoids from Radix Scrophulariae (R. Scrophulariae) offer a range of benefits, including anti-inflammatory, antioxidant, antitumour, antibacterial, antiviral, and antiallergic effects. Although previous studies have indicated the potential of R. Scrophulariae for hyperthyroidism prevention and treatment, the specific active compounds involved and their mechanisms of action are not fully understood. This study explored the effects of high-polarity iridoid glycosides from R. Scrophulariae on hyperthyroidism induced in rats by levothyroxine sodium. The experimental design included a control group, a hyperthyroidism model group, and a group treated with iridoid glycosides. Serum triiodothyronine (T3) and thyroxine (T4) levels were quantified using an enzyme-linked immunosorbent assay (ELISA). Transcriptomic and proteomic analyses were applied to liver samples to identify differentially expressed genes and proteins. These analyses were complemented by trend analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis. The effectiveness of key factors was further examined through molecular biology techniques. ELISA results indicated a notable increase in T3 and T4 in the hyperthyroid rats, which was significantly mitigated by treatment with iridoid glycosides. Transcriptomic analysis revealed 6 upregulated and 6 downregulated genes in the model group, showing marked improvement following treatment. Proteomic analysis revealed changes in 30 upregulated and 50 downregulated proteins, with improvements observed upon treatment. The PI3K-Akt signalling pathway was investigated through KEGG enrichment analysis. Molecular biology methods verified the upregulation of Spp1, Thbs1, PI3K, and Akt in the model group, which was reversed in the treatment group. This study revealed that highly polar iridoids from R. Scrophulariae can modulate the Spp1 gene and Thbs1 protein via the PI3K-Akt signalling pathway, suggesting a therapeutic benefit for hyperthyroidism and providing a basis for drug development targeting this condition.

Perioperative Care of a Child With Hyperthyroidism

In pediatric-aged patients, hyperthyroidism generally results from the autoimmune disorder, Graves' disease (GD). Excessive levels of thyroid hormones (triiodothyronine and thyroxine) result in irritability, emotional lability, nervousness, tremors, palpitations, tachycardia, and arrhythmias. The risk of morbidity and mortality is increased when surgical intervention is required in patients with hyperthyroidism due to the potential for the development of thyroid storm (TS). A 3-year, 1-month-old child with a past medical history of GD presented for total thyroidectomy when pharmacologic control with methimazole was not feasible due to intolerance following development of a serum sickness-like illness. Prior to surgery, his thyrotoxicosis symptoms worsened with fever, tachycardia, diaphoresis, and hypertension. He subsequently developed TS and was admitted to the pediatric intensive care unit where management included hydrocortisone, potassium iodide, and β-adrenergic blockade with esmolol and propranolol. Thyroid studies improved prior to surgery, and a total thyroidectomy was successfully completed. Corticosteroid therapy was slowly tapered as an outpatient, and he was discharged home on hospital day 9. Following discharge, his signs and symptoms of thyrotoxicosis resolved, and he was started on oral levothyroxine replacement therapy. The remainder of his postoperative and post-discharge course were unremarkable. Only two case reports of perioperative pediatric TS have been published in the past 20 years. Our case serves as an important reminder of the signs of TS in children and to outline the treatment options in a pediatric patient, especially in those unable to tolerate first-line pharmacologic therapies such as methimazole or propylthiouracil.