Thyrotoxicosis in children

Longitudinal follow-up of pediatric Graves' disease in preschool children: Clinical characteristics and a case report

RATIONALE

Pediatric Graves' disease at preschool age is a rare condition. Previous reports have indicated that adolescents with this disease are girls. Pediatric Graves' ophthalmopathy in young children is rare, and long-term follow-up reports are lacking.

PATIENT CONCERNS

The patient had hyperthyroidism and bilateral proptosis for 2 years, but she was only 4 years old.

DIAGNOSES

The blood test revealed hyperthyroidism and the ophthalmic examination revealed proptosis. The patient had Graves' disease and Graves' ophthalmopathy.

INTERVENTIONS

Initially, she was followed up in the pediatric department. Bilateral proptosis developed, and she was brought to the ophthalmology department for assistance. Orbital computed tomography revealed borderline enlargement of the extraocular muscles bilaterally. Other initial clinical findings included bilateral upper and lower eyelid trichiasis and mild punctate epithelial erosions of the cornea. She received conservative medical treatment in the ophthalmology department.

OUTCOMES

Remission of hyperthyroidism was achieved 2 years after medical control. No elevated intraocular pressure, strabismus, or optic neuropathy developed during follow-up. Significant cosmetic improvement and gradual resolution of punctate epithelial erosions were found over 10 years. Finally, the patient had only mild bilateral lower trichiasis.

LESSONS

Longitudinal follow-up revealed that the ocular manifestations of proptosis and eyelid trichiasis may have good outcomes. Proptosis gradually improved as the patient grew up.

Endothelial dysfunction in children with newly diagnosed Graves' disease

The most frequent cause of hyperthyroidism in children is Graves' disease (GD). Vascular endothelium is a specific target of thyroid hormone. The purpose of this study is to assess flow-mediated dilatation (FMD)% and serum von Willebrand factor (vWF) levels in children with newly diagnosed GD to reflect the extent of endothelial dysfunction in those children. In this study, 40 children with newly discovered GD and 40 children who were healthy served as the control group. Both patients and controls had anthropometric assessment, as well as measurements of fasting lipids, glucose, insulin, high-sensitivity C-reactive protein (hs-CRP), TSH, and free thyroxine (FT4 and FT3), thyrotropin receptor antibodies TRAbs and vWF. Noninvasive ultrasound was utilized to quantify the carotid arteries' intima-media thickness and the brachial artery's FMD. Patients reported significantly reduced FMD response and greater vWF and hs-CRP levels compared to controls (P = 0.001 for each). In multivariate analysis, we reported that vWF was significantly correlated with TSH (OR 2.5, 95% CI 1.32-5.32, P = 0.001), FT3 (OR 3.4, 95% CI 1.45-3.55, P = 0.001), TRAb (OR 2.1, 95% CI 1.16-2.23, P = 0.01), and FMD% (OR 4.2, 95% CI 1.18-8.23, P = 0.001).  Conclusions: Children with newly diagnosed GD have endothelial dysfunction, which is shown by impaired FMD and increased vWF. These findings support the idea that GD may need to be treated as soon as possible. What is Known: • Graves' disease is the most common cause of hyperthyroidism in children. • vWF is a reliable marker for detection of vascular endothelial dysfunction. What is New: • Children with newly diagnosed Graves' disease may have endothelial dysfunction as reflected by impairment of FMD and raised vWF level. • Measurement of vWF level in children with newly diagnosed Graves' disease can be used for early detection of endothelial dysfunction.

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

Previous studies have identified frequent comorbid neuropsychiatric disorders and conditions in adults with thyrotoxicosis. These studies are scarce or even lacking in pediatric population. This work aimed to study the behavior of children and adolescents with Graves’ disease (GD). This study included 35 children with GD (boys = 15; girls = 25; mean age: 11.45±1.50yrs) and 40 healthy children (boys = 20; girls = 20; mean age: 12.54±1.62yrs). Behavior was assessed using Child Behavior Checklist (CBCL). Children with GD were assessed during periods of thyroid hormone elevation (active disease) and normalized thyroid hormones (with anti-thyroid drugs or ATDs). Compared to healthy children, patients during periods of thyroid hormone elevation (74.29%) and normalized thyroid hormones (31.43%) had higher frequencies of behavioral abnormalities and scorings of total CBCL scale (P = 0.01; P = 0.04, respectively) and its subscales’ [Anxious/Depressed (P = 0.02; P = 0.04), Withdrawn/Depressed (P = 0.03; P = 0.04) and Somatic Complaints (P = 0.03; P = 0.127) and Social (P = 0.01; P = 0.225), Thought (P = 0.01; P = 0.128) and Attention (P = 0.01; P = 0.01) problems], indicating internalizing and externalizing problems. The majority of patients had at least two different behavioral problems. Marked improvement was found during period of normalized thyroid hormones (P = 0.001). Correlation analyses showed significant associations between total CBCL scoring and age at onset (P = 0.01; P = 0.001) and lower concentrations of thyroid stimulating hormone (TSH) (P = 0.001; P = 0.04) and higher concentrations of free thyroxine (fT4) (P = 0.01; P = 0.02), triiodothyronine (fT3) (P = 0.01; P = 0.03) and thyrotropin receptor antibodies (TRAbs) (P = 0.001; P = 0.01) during periods of thyroid hormone elevation and normalized thyroid hormones, respectively. Multiple linear regression analysis showed that "at presentation" lower concentrations of TSH (P = 0.001; P = 0.03) and higher concentrations of fT4 (P = 0.001, P = 0.01), fT3 (P = 0.01; P = 0.06) and TRAbs (P = 0.001; P = 0.001) were predictors of behavioral problems during periods of active disease and normalized thyroid hormones. We conclude that GD is associated with higher frequencies and severities of anxiety, depression and inattention during periods of thyroid hormone elevation as well as normalized thyroid hormones with ATDs. Therefore, early diagnosis and optimizing management are required to improve children’s social life.

Superb Microvascular Imaging in the Evaluation of Pediatric Graves Disease and Hashimoto Thyroiditis

OBJECTIVES

We aimed to investigate the differences between spectral Doppler and Superb Microvascular Imaging (SMI; Canon Medical Systems, Tokyo, Japan) findings in children with Hashimoto thyroiditis (HT) and Graves disease (GD) compared to healthy control participants.

METHODS

The study included 34 patients with GD, 37 patients with HT, and 22 healthy volunteers. All patients with HT and 11 patients with GD were euthyroid; 23 patients with GD had symptoms of hyperthyroidism and had thyrotropin values of less than 0.5 mIU/L. Thyroid volumes, mean resistive indices, and peak systolic velocities along with vascularity indices (VIs) on Superb Microvascular Imaging were measured.

RESULTS

Patients with GD had a significantly higher mean thyroid volume (P < .001; right lobe, 11.80 mL; left lobe, 9.10 mL) and peak systolic velocity (right, 32.5 cm/s; left, 30 cm/s) with a lower resistive index (right, 0.48%; left, 0.48%) compared to patients with HT (right, 8.78 mL, 20 cm/s, 0.55%; left, 7.41 mL, 20 cm/s, 0.55%, respectively) and also control participants (right, 4.59 mL, 15 cm/s, 0.56%; left, 3.52 mL, 15 cm/s, 0.54%). Patients with GD had a significantly higher median VI (right, 25%; left, 26%) compared to patients with HT (right, 11%; left, 13%) and control participants (right, 8%; left, 8%). When patients with GD were categorized as euthyroid and hyperthyroid based on thyrotropin levels and clinical symptoms, both euthyroid and hyperthyroid patients with GD had significantly higher thyroid volumes compared to patients with HT (P < .001). Hyperthyroid patients with GD had higher thyroid volumes compared to euthyroid patients with GD; however, the difference failed to reach statistical significance. A significant strong positive correlation with the VI and thyrotropin receptor autoantibody levels (r = 0.696) was found. The highest area under the curve was obtained for the right lobe VI (0.885), followed by the left lobe VI (0.872), right lobe volume (0.828), and peak systolic velocity (0.810). The optimal cutoff VI value for distinguishing between HT and GD was 17.35% with sensitivity, specificity, and diagnostic accuracy of 85.3%, 78.4%, and 81.7%, respectively.

CONCLUSIONS

Superb Microvascular Imaging is a new method that can detect subtle vascularity changes with higher accuracy compared to spectral Doppler parameters in distinguishing between HT and GD.

The impact of thyroid diseases starting from birth on reproductive function

The aim of this review is to provide relevant information regarding the impact of thyroid disease, starting from birth and mainly concerning hyperthyroidism and hypothyroidism, on reproduction. Hyperthyroidism occurs much less commonly in children than hypothyroidism, with Graves' disease (GD) being the most common cause of thyrotoxicosis in children. Children born with neonatal GD have no defects in the reproductive system that could be related to hyperthyroidism. Current treatment options include antithyroid drugs (ATD), surgery, and radioactive iodine (RAI). In males, normal thyroid function seems important, at least in some parameters, for maintenance of semen quality via genomic or non-genomic mechanisms, either by locally acting on Sertoli cells, Leydig cells, or germ cells, or by affecting crosstalk between the HPT axis and the HPG axis. Sexual behavior may also be affected in thyroxic men, although many of these patients may have normal free testosterone levels. In women, menstrual irregularities are the most common reproduction-related symptoms in thyrotoxicosis, while this disorder is also associated with reduced fertility, although most women remain ovulatory. An increase in sex hormone-binding globulin (SHBG) and androgens, thyroid autoimmunity, and an impact on uterine oxidative stress are the main pathophysiological mechanisms which may influence female fertility. Thyroid hormones are responsible for normal growth and development during pre- and postnatal life, congenital hypothyroidism (CH) being the most common cause of neonatal thyroid disorders, affecting about one newborn infant in 3500. The reproductive tract appears to develop normally in cretins. Today, CH-screening programs allow for early identification and treatment, and, as a result, affected children now achieve normal or near-normal development. Hypothyroidism in males is associated with decreased libido or impotence. Although little is currently known about the effects of hypothyroidism on spermatogenesis and fertility, it has been established that sperm morphology and motility are mainly affected. In women of reproductive age, hypothyroidism results in changes in cycle length and amount of bleeding. Moreover, a negative effect on fertility and higher miscarriage rates has also been described.

RETRACTED: Factors Affecting Readmission After Pediatric Thyroid Resection: A National Surgical Quality Improvement Program-Pediatric Evaluation

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the authors because of an error involving the dataset which doubled the reported sample size, thereby invalidating the analysis. The authors reported this error immediately upon discovering the problem. The authors regret the error.

Long-term Methimazole Therapy in Juvenile Graves' Disease: A Randomized Trial

BACKGROUND AND OBJECTIVES

Recent studies show that long-term (LT) antithyroid drugs reduce relapse of hyperthyroidism in patients with Graves' disease. Our objective was to evaluate the effectiveness and safety of LT methimazole treatment and to compare remission rates in Graves' disease patients after LT and short-term (ST) therapy.

METHODS

In this randomized, parallel group trial, 66 consecutive patients with untreated juvenile Graves' hyperthyroidism were enrolled. After a median 22 months of methimazole treatment, 56 patients were randomly assigned to either continue low-dose methimazole treatment (n = 24, LT group) or to discontinue treatment (n = 24, ST group). Twenty-four patients in LT group completed 96 to 120 months of methimazole treatment. Patients in both groups were managed for 48 months after discontinuation of treatment.

RESULTS

Except for 3 cases of cutaneous reactions, no other adverse events were observed throughout 120 months of methimazole therapy. Serum free thyroxine, triiodothyronine, thyrotropin, and thyrotropin receptor antibody remained normal, and the required daily dosage of methimazole was gradually decreased from 5.17 ± 1.05 mg at 22 months to 3.5 ± 1.3 mg between 96 and 120 months of treatment (P < .001). Hyperthyroidism was cured in 92% and 88% of LT patients and in 46% and 33% of ST patients, 1 and 4 years after methimazole withdrawal, respectively.

CONCLUSIONS

LT methimazole treatment of 96 to 120 months is safe and effective for treatment of juvenile Graves' disease. The four-year cure rate of hyperthyroidism with LT methimazole treatment is almost 3 times more than that of ST methimazole treatment.

Disease Burden and Outcome in Children and Young Adults With Concurrent Graves Disease and Differentiated Thyroid Carcinoma

CONTEXT

Adults with differentiated thyroid cancer (DTC) and Graves disease (GD) demonstrate a greater reported disease burden and aggressive DTC behavior. To date, no studies have examined the impact and long-term outcome of concurrent GD and DTC (GD-DTC) in children and young adults.

DESIGN

Single institution, retrospective longitudinal cohort study between 1997 and 2016.

PARTICIPANTS

One hundred thirty-nine children and young adults with DTC, diagnosed at median age 15 (range, 5 to 23) years, compared with 12 patients with GD-DTC, median age 18 (range, 12 to 20) years.

MAJOR OUTCOME MEASURES

Patient demographics, preoperative imaging, fine needle aspiration (FNA) cytology, operative and pathological reports, laboratory studies, treatment, and subsequent 2-year outcomes.

RESULTS

Compared with DTC, patients with GD-DTC were significantly older at the time of DTC diagnosis (P < 0.01). Patients with GD-DTC were more likely to exhibit microcarcinoma (P < 0.01), and 2 of 12 (17%) demonstrated tall cell variant papillary thyroid cancer (PTC) vs 2 of 139 (2%) in patients who had DTC alone (P = 0.03). Although patients with DTC showed greater lymphovascular invasion (60% vs 25%; P = 0.03), no group differences were noted in extrathyroidal extension, regional lymph node, and distant or lung metastasis. There were no group differences in the 2-year outcome for remission, persistent disease, or recurrence.

CONCLUSIONS

Concurrent DTC in pediatric patients with GD is not associated with a greater disease burden at presentation and shows no significant difference in 2-year outcomes compared with DTC alone. Similar to adults, microcarcinoma and tall cell variant PTC is prevalent in pediatric patients with GD-DTC. For patients who have GD-DTC with an identified nodule on ultrasound imaging prior to definitive therapy, FNA biopsy is recommended to guide definitive treatment.

Management of thyrotoxicosis in children and adolescents: 35 years' experience in 304 patients

BACKGROUND

Diffuse toxic goiter accounts for about 15% of all childhood thyroid diseases. There is great controversy over the management of Graves' disease in children and adolescents. This article reports our experience in 304 children and juvenile patients with Graves' disease.

METHODS

Between 1981 and 2015, 304 patients aged 5-19 years with diffuse toxic goiter were studied, of whom 296 patients were treated with antithyroid drugs (ATD) for 18 months. Patients with persistent or relapsed hyperthyroidism who refused ablative therapy with surgery or radioiodine were managed with continuous methimazole (MMI) treatment.

RESULTS

In 304 patients (245 females and 59 males), the mean age was 15.6±2.6 years. After 18 months of ATD therapy, 37 remained in remission and of the 128 who relapsed, two, 29 and 97 patients chose surgery, continuous ATD and radioiodine therapy, respectively. Of the 136 patients who received radioiodine, 66.2% became hypothyroid. Twenty-nine patients received continuous ATD therapy for 5.7±2.4 years. The mean MMI dose was 4.6±12 mg daily, no serious complications occurred and all of them remained euthyroid during the follow-up. Less abnormal thyroid-stimulating hormone (TSH) values were observed in these patients, as compared to patients who were on a maintenance dose of levothyroxine after radioiodine induced hypothyroidism.

CONCLUSIONS

Original treatment with ATD and subsequent radioiodine therapy remain the mainstay of treatment for juvenile hyperthyroidism. Continuous ATD administration may be considered as another treatment modality for hyperthyroidism.

Left ventricular functions in children with newly diagnosed Graves' disease. A single-center study from Upper Egypt

This study aimed to evaluate the left ventricular (LV) functions in a cohort of children with Graves' disease (GD). This is a cross-sectional case-control study. It included 36 children with GD and 36 healthy children matched for age and gender. Thyroid hormones (TSH, FT4, and FT3) and anti-thyroid autoantibodies [anti-thyroid peroxidase (anti-TPO), thyrotropin receptor (TRAbs), and thyroglobulin antibodies] were measured. Conventional and tissue Doppler imaging (TDI) echocardiographies were used to assess left ventricular systolic and diastolic functions. LV mass index (LVMI) and myocardial performance index (MPI) were also measured. Compared to healthy children, conventional echocardiography of patients with GD revealed higher LVMI (P = 0.001) indicating LV hypertrophy but normal LV functions while TDI revealed lower Em/Am ratio indicating LV diastolic dysfunction (P = 0.001). Significant correlations were reported between FT4 with LVMI (P = 0.05), Em/Am (P = 0.01), and MPI (P = 0.01). In multivariate analysis, a positive correlation was identified between FT4 with MPI (OR = 1.17; 95% CI = 1.09-1.15; P = 0.001).

CONCLUSIONS

Children with newly diagnosed GD may have significant subclinical changes in LV structure and function (diastolic and global). TDI is more sensitive than conventional Doppler in detecting LV dysfunction. These findings highlight the importance of early monitoring of children with GD for left ventricular mass index and diastolic function. What is Known: • There is an increased risk for cardiac abnormalities in children with Graves' disease (GD). • Limited studies assessed left ventricular function in patients with GD. What is New: • Children with newly diagnosed GD may have significant subclinical changes in left ventricular structure and functions. • Children with newly diagnosed GD should be monitored for left ventricular mass index and diastolic function.

Predictive factors for early response to methimazole in children and adolescents with Graves disease: a single-institute study between 1993 and 2013

PURPOSE

We aimed to investigate the predictive factors for early response to methimazole (MMI) in pediatric patients with Graves disease (GD).

METHODS

Our study included 44 pediatric patients who were diagnosed with GD between January 1, 1993, and December 31, 2013, and were available for follow-up, achieving a normalization of thyroid functions (TFs) at the Chonbuk National University Hospital Pediatric Department. We retrospectively analyzed TFs such as tri-iodothyronine (T3), free thyroxine (fT4), thyroid-stimulating hormone (TSH), and thyroid antibody levels at diagnosis. We also examined their family history of thyroid disease, symptoms at presentation, and normalization time for TF after treatment. We divided our clinical series of patients into the following 4 age groups: <7 years old, 7-12 years old, 13-15 years old, and 16-18 years old.

RESULTS

At diagnosis, the time of normalization of T3 was significantly shorter in the higher antimicrosomal antibody (AMA) group compared with the lower AMA group (2.53 months vs. 6.18 months) (P<0.05). However, the time of normalization of T3/fT4/TSH had no significant correlations with other variables such as age, sex, a family history of thyroid diseases, thyroglobulin, thyroid-stimulating immunoglobulin, or antithyroglobulin antibody (ATA).

CONCLUSION

Higher serological titers of AMA at diagnosis may have prognostic value in the response to initial MMI treatment in pediatric hyperthyroid GD patients.

Nuclear Medicine in Thyroid Diseases in Pediatric and Adolescent Patients

Both benign and malignant diseases of the thyroid are rare in the pediatric and adolescent population, except congenital hypothyroidism. Nuclear medicine plays a major role, both in the diagnosis and therapy of thyroid pathologies. Use of radioactivity in pediatric population is strictly controlled due to possible side effects such as secondary cancers; therefore, management of pediatric patients requires detailed literature knowledge. This article aims to overview current algorithms in the management of thyroid diseases and use of radionuclide therapy in pediatric and adolescent population.

Pediatric Thyroid Carcinoma in Patients with Graves' Disease: The Role of Ultrasound in Selecting Patients for Definitive Therapy

BACKGROUND/AIMS

Pediatric Graves' disease (GD) accounts for 10-15% of all thyroid disorders in patients ≤18 years and is treated with antithyroid medication or definitive therapy [radioactive iodine (RAI) ablation vs. surgery]. Patients with GD may have concurrent differentiated thyroid cancer (DTC). DTC prevalence in pediatric GD is not well established. We examined the prevalence of DTC in pediatric GD and the role of preoperative thyroid ultrasound (US) in selecting the appropriate definitive therapy.

METHODS

This is a single-institution, retrospective, cross-sectional study of 32 GD patients with a median age of 11 years (range 3-18) who underwent total thyroidectomy as the definitive treatment between 2005 and 2014.

RESULTS

DTC was identified in 22% of the GD patients. A total of 97% completed preoperative thyroid US, and thyroid nodules were identified in 13/32 patients (41%). Preoperative fine needle aspiration (FNA) biopsy was performed in 6/13 patients, accounting for four preoperative diagnoses of concurrent DTC. Extra-thyroidal extension was present in 4/7 (63%), regional lymph node metastasis in 3/7 (43%), and lung metastasis in 2/7 patients (29%).

CONCLUSIONS

Concurrent DTC occurs in pediatric GD patients. Thyroid US is an efficient tool for selecting patients for thyroidectomy. For patients with a nodule on US before definitive therapy, FNA should be performed to appropriately select thyroidectomy versus RAI ablation. © 2015 S. Karger AG, Basel.

Influence of prior carbimazole on the outcome of radioiodine therapy in pediatric and adolescent Graves' disease

OBJECTIVE OF THE STUDY

Therapeutic options for pediatric Graves' disease (PGD) include antithyroid drug therapy (ATD) as the first line and radioiodine (I-131) therapy as the second line of treatment. To date, controversies persist regarding the true effect of prior ATD in the outcome of I-131 therapy in PGD. This study evaluated the effect of prior carbimazole treatment on the outcome of I-131 therapy in PGD.

METHODS

This is a retrospective study covering the years 1995-2012, with a median follow-up of 75 months. Records of 114 children (84 girls and 30 boys, age range: 5-20 years, mean 24-h radioiodine uptake, 58%) who had clinically and biochemically proven Graves' disease irrespective of prior ATD therapy were included. All patients were treated with fixed doses of 5 mCi (185 MBq) I-131 for Graves' disease; 74 had undergone prior carbimazole treatment (group 1) and 40 were drug naive (group 2). The endpoint of follow-up was stable euthyroid or hypothyroid in patients. The effect of prior carbimazole treatment on the outcome of I-131 therapy in PGD patients was evaluated. The success of radioiodine therapy was defined as the cure of hyperthyroidism. Variables were analyzed to identify the potential predictive factors for euthyroidism/hypothyroidism after treatment.

RESULTS

The cure rate was 70% in group 1 and 83% in group 2 with a single dose of radioiodine (P=0.299). The success rate achieved at the end of 1-year follow-up in group 1 and group 2 was 81 and 87%, respectively (P=0.401). No independent predictor was associated with success or failure of treatment. At the median follow-up of 75 months (range: 12-216 months), 76% of patients were hypothyroid on replacement doses of levothyroxine and 24% still continued to be euthyroid.

CONCLUSION

Prior carbimazole treatment does not alter the outcome of radioiodine therapy in PGD.

Effects of short-term potassium iodide treatment for thyrotoxicosis due to Graves disease in children and adolescents

PURPOSE

Graves disease is the most common cause of hyperthyroidism in children. Inorganic iodide has been used in combination with antithyroid drugs for more effective normalization of thyroid hormones in some cases of severe thyrotoxicosis. This study aimed to investigate clinical characteristics of childhood thyrotoxicosis and effectiveness of inorganic iodide in the early phase of treatment.

METHODS

Sixty-seven pediatric patients (53 girls/14 boys, 11.1±3.4 years of age), with newly diagnosed thyrotoxicosis due to Graves disease were recruited. Forty-nine patients were treated with antithyroid drugs alone, while 18 patients were treated with combination of antithyroid drugs and potassium iodide. Initial thyroid function tests and levels of thyroid antibodies were recorded for all patients. Thyroid function tests were repeated 2 and 8 weeks after the initiation of treatment. Measurement thyroid antibodies were done 8 weeks after the initiation of treatment.

RESULTS

Mean triiodothyronine and free thyroxine levels were significantly lower (P<0.05) in the group receiving combined therapy of antithyroid drugs and potassium iodide after 2 weeks of treatment compared to the patients receiving antithyroid drugs alone. Eight weeks after the initiation of treatment, thyroid function tests in the two groups did not show significant differences.

CONCLUSION

The use of potassium iodide in combination with antithyroid drug is effective for more rapid normalization of thyroid hormones in the early phase treatment of childhood thyrotoxicosis, but larger studies with adequate power are needed in future.

Radioactive iodine for thyrotoxicosis in childhood and adolescence: treatment and outcomes

OBJECTIVE

The aim of the present study was to evaluate the outcome of radioiodine treatment in thyrotoxicosis in childhood and adolescence.

METHODS

This was a retrospective study of 27 patients (ages 7.2- 19.8 years) with a diagnosis of thyrotoxicosis who received iodine-131 (I-131) treatment from January 2007 to December 2011 in the Nuclear Medicine Division, Department of Radiology, Faculty of Medicine, Chiang Mai University. Gender, duration of antithyroid drug (ATD) treatment, 24-hour I-131 uptake, thyroid weight, total dose and number of treatments with I-131, and thyroid status at 6 months after treatment were recorded.

RESULTS

The outcomes of 27 patients (85.2% female, 14.8% male) treated with radioactive iodine were analyzed to assess the effectiveness of therapy as related to dose and gland size. All children and adolescents received 150 µCi of I-131/g of thyroid tissue (n=27). Six 6 months after treatment, 44.5% of the patients were hyperthyroid, 14.8% were euthyroid, and 40.7% were hypothyroid. Of the 12 cases with hyperthyroidism, 2 cases needed a second dose of I-131 treatment, and they finally reached a hypothyroid state. The patients were classified into 2 groups according to treatment success (euthyroid and hypothyroid) and treatment failure (hyperthyroid). There were no significant differences in age, gender, duration of ATD treatment, 2- and 24-hour I-131 uptake, thyroid weight, and total I-131 dose between these two groups.

CONCLUSIONS

Radioiodine treatment is safe and effective for thyrotoxicosis in childhood and adolescence. It is suitable as a good second-line therapy for patients with severe complications, those who show poor compliance, and those who fail to respond to ATD treatment.

[Graves disease and IgA deficiency as manifestations of 22q11.2 deletion syndrome]

The 22q11.2 deletion syndrome (22q11.2DS) is related to a high phenotypic variability including the velocardiofacial/DiGeorge spectrum. Autoimmune, endocrine and immunodeficiency manifestations have been reportedly associated with the syndrome. The objective of this study was to report a case of 22q11.2DS associated with IgA deficiency and Graves disease and review literature in order to verify the frequency of syndrome alterations. Autoimmune disorders have been increasingly related to 22q11.2DS, and new phenotypes are being incorporated in the clinical spectrum of this syndrome. In our study we found that Graves disease in association with 22q11.2DS was reported in only sixteen patients, and fifteen cases were described in the last 13 years. Based on the incidence and on the amplitude of this recognized spectrum, we reinforce the findings of literature that Graves disease should be included on the 22q11.2DS manifestations, which would lead us to seek it with 22q11.2 deletion patients.

Treatment of pediatric Graves' disease is associated with excessive weight gain

CONTEXT

Little information is available about changes in body weight and body mass index in children before, during, and after treatment for Graves' disease (GD).

OBJECTIVE

Our objective was to examine changes in body weight after treatment for GD in children as related to clinical features.

DESIGN

The medical records of 43 pediatric patients with GD [35 girls and eight boys, aged 4.0-18.5 (mean 10.9) yr] were examined. Patients were included if clinical data were available for 1 yr before and after the diagnosis of GD.

MAIN OUTCOME MEASURES

Weight, height, body mass index (BMI) z-scores, and thyroid hormone levels were assessed.

RESULTS

Overall, patients presented with an average BMI z-score of -0.02 ± 1.05 that was not different from the normal population (P = 0.921) or their premorbid values (P = 0.07). However, in the subset of patients who were initially overweight or obese in the premorbid state, the BMI decreased significantly during the development of hyperthyroidism (P < 0.05). After initiation of treatment, patients gained significant amounts of weight over the first 6 months leading to elevated BMI z-scores (P < 0.0001), and elevations in BMI persisted in about 25% of the patients.

CONCLUSION

Excessive weight gain within 6 months of treatment is seen in children treated for GD, and the gain in weight can persist.

Seizure and encephalopathy associated with thyroid storm in children

Thyroid storm with seizures is very rare in children. The authors report 3 children with thyroid storm who had a seizure in the absence of a history of neurologic disease. Acute medical management with propylthiouracil, Lugol's iodine solution, hydrocortisone, and propranolol led to a complete resolution of the symptoms. Patients with thyroid storm may be predisposed to the development of neuropsychiatric change. Early recognition and treatment of thyroid storm are essential to reduce morbidity and mortality from this disorder.

Approach to the pediatric patient with Graves' disease: when is definitive therapy warranted?

Pediatric Graves' disease accounts for 10-15% of thyroid disorders in patients less than 18 yr of age. The onset of symptoms may be insidious and subsequently associated with a delay in diagnosis. Decreased concentration and poor school performance are frequent complaints and can be quite frustrating for the patient and family. Severe ophthalmopathy is uncommon. The diagnosis is established by the findings of an increased heart rate and goiter in the setting of a suppressed TSH and elevated T(3) and/or T(4). The majority of pediatric patients are initially placed on antithyroid medications and maintained on these medications for prolonged periods of time in hopes of achieving remission. Unfortunately, for many children and adolescents remission is unattainable, ultimately occurring in only 15-30% of patients. Several recent studies have suggested that the age of the patient, the degree of thyrotoxicosis at diagnosis, the initial response to therapy, and the level of TSH receptor antibodies serve as reasonable predictors of remission and relapse. However, a consensus on the utility of these markers has not been reached. The present clinical case describes an adolescent with Graves' disease and highlights the negative impact that prolonged medical therapy can have on quality of life and school performance; it reviews pertinent data on the diagnosis, comorbidities, and treatment options; and it identifies gaps in knowledge for when definitive therapy should be pursued. The case serves as a reminder that earlier discussion and decision for definitive therapy should be more commonplace in caring for our pediatric patients with Graves' disease.

Toxicological considerations for antithyroid drugs in children

INTRODUCTION

Propylthiouracil (PTU), methimazole (MMI) and carbimazole are indicated for the treatment of hyperthyroidism in adult and pediatric patients. The aim of this review is to present all the relevant information regarding the use of antithyroid drugs (ATD) in pediatric thyrotoxic cases, the pediatric toxicology of ATD and the warning which has recently been issued for PTU by the FDA.

AREAS COVERED

Epidemiology, diagnosis and treatment of pediatric thyrotoxicosis are all presented in this article. The authors also extensively discuss the details regarding the pharmacology, bioactivation, biodisposition, bioavailability and pharmacokinetic properties of the two main ATD (MMI and PTU).

EXPERT OPINION

The FDA recently reported that use of PTU is associated with a higher risk for clinically serious or fatal liver injury compared to MMI in both adult and pediatric patients. They also found that congenital malformations were reported approximately three times more often with prenatal exposure to MMI compared with PTU and especially with the use of MMI during the first trimester of pregnancy. The authors believe that PTU should not be used in pediatric patients unless the patient is allergic to or intolerant of MMI, and there are no other treatment options available. That being said, PTU may be the treatment of choice during, and just before, the first trimester of pregnancy.

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.

Radioiodine treatment for pediatric hyperthyroid Grave's disease

Grave's disease (GD) is an autoimmune disease in which excessive amounts of thyroid hormones circulate in the blood. Treatment for pediatric GD includes (1) antithyroid drugs (ATD), (2) radioiodine, and (3) thyroidectomy. Yet, the optimal therapy remains controversial. We collected studies from all electronically available sources as well as from conferences held in China. All studies using radioiodine and/or ATD and/or thyroidectomy were included. Information was found on 1,874 pediatric GD patients treated with radioiodine, 1,279 patients treated with ATD and 1,362 patients treated surgically. The cure rate for radioiodine was 49.8%; the incidence of hypothyroidism, 37.8%; of relapse, 6.3%; of adverse effects, 1.55%; and of drop outs, 0.6%. These data show that radioiodine treatment is safe and effective in pediatric GD with significant lower incidence of relapse and adverse effects but significantly higher incidence of hypothyroidism as compared with both ATD and thyroidectomy. For the time being, radioiodine treatment for pediatric GD remains an excellent first-line therapy and a good second-line therapy for patients with ATD failure, severe complications, or poor compliance.

Benzylthiouracil-induced glomerulonephritis

Vasculitis is a rare complication of antithyroid drugs (ATDs). It was first described with Propylthiouracil (PTU). We report a new case of antineutrophil cytoplasmic antibody (ANCA) vasculitis with glomerulonephritis induced by Benzylthiouracile (BTU). A 50-year-old man with Graves disease treated with BTU developed general malaise and haematuria without skin rash or respiratory involvement. Laboratory data revealed acute renal failure with proteinuria and haematuria. An indirect immunofluorescence test for ANCA was positive, showing a perinuclear pattern with specificity antimyeloperoxidase (MPO). A renal biopsy was performed and revealed pauci-immune extracapillary glomerular nephropathy and necrotic vasculitis lesions. Based on these findings we concluded to the diagnosis of rapidly progressive glomerulonephritis associated with ANCA induced by BTU therapy. The drug was therefore discontinued and the patient was treated with steroids and immunosuppressive treatment during 3 months. Renal failure, proteinuria and haematuria significantly improved within 2 months. However, P-ANCA remained positive until 10 months after drug withdrawal. Thyroid function was kept within normal range using iodine solution. We demonstrated clearly that BTU may induce severe forms of vasculitis with glomerulonephritis. Thus, the ANCA must be measured when confronted to systemic manifestation during treatment.

Radioiodine treatment for pediatric Graves' disease

BACKGROUND

Pediatric Graves' disease (GD) is an autoimmune disease in which excessive amounts of thyroid hormones circulate in the blood. Treatments for pediatric GD include antithyroid drugs (ATD), thyroidectomy and radioiodine. Up to date, the optimal therapy remains controversial.

OBJECTIVES

To assess the effects of radioiodine treatment for pediatric GD.

SEARCH STRATEGY

Studies were obtained from computerized searches of MEDLINE, EMBASE, The Cochrane Library, China National Infrastructure (CNKI) and paper collections of conferences held in Chinese.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials and prospective cohort studies comparing the effects of radioiodine with ATD or thyroidectomy with a duration of follow-up at least one year.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality, extracted data and interviewed authors of all potentially relevant studies by telephone or electronic mail to verify randomization procedures. One author entered data into a data extraction form and another author verified the results of this procedure.

MAIN RESULTS

Two prospective controlled clinical trials involving 167 patients were included. All of them were of low quality. Radioiodine treatment versus ATD showed benefits in achieving euthyroidism (relative risk (RR) 1.70, 95% confidence interval (CI) 1.29 to 2.24). Radioiodine treatment showed a higher incidence of hypothyroidism compared with ATD (RR 6.46, 95% CI 1.16 to 35.81). No significant differences in modifying Graves' opthalmopathy (worsening or appearance) between radioiodine treatment and ATD (RR 1.30, 95% CI 0.56 to 3.00) were observed. No trial evaluated mortality, health related quality of life, economic outcomes or compliance with treatments.

AUTHORS' CONCLUSIONS

The limited results in Chinese suggest that a gland specific lower dosage of radioiodine treatment is potentially effective for pediatric GD, but a significant higher incidence of hypothyroidism compared with ATD was observed. However, we could not identify a well-designed trial to provide strong evidence for radioiodine in the treatment of pediatric GD. High-quality randomised controlled clinical trials are needed to guide treatment choice.

Clinical and endocrine features and long-term outcome of Graves' disease in early childhood

Hyperthyroidism is rare in early childhood and most commonly caused by Graves' disease. We report 14 children (4 boys, 10 girls) aged 3.4-7.5 yr. At diagnosis, all patients had weight loss, hyperkinetic activity, tachycardia, difficulty sleeping, and poor concentration and 11 presented with proptosis. Four patients developed long-term neuropsychological problems. There was a family history in 7 cases. All patients had goiters, clinically assessed to be large and diffuse in 21%, medium-sized in 43%, and small in 36%. At diagnosis, height was increased with median (range) height; 1.25 standard deviation score (SDS) (-0.2-5.24) and body mass index (BMI) was decreased; -0.48 SDS (-1.65-1.26). Height and BMI SDS values were statistically different (p<0.032) Bone age was advanced in 4 of 5 children, who had assessments. Total or free T4 levels were elevated and TSH was undetectable. Ninety percent of patients (12/14) had positive thyroid peroxidase autoantibodies, mean level 680 IU/ml (range 50-1347). Initial treatment was with antithyroid medication using carbimazole; median dose 0.75 mg/kg/day (no.=13) or propylthiouracyl 15 mg/kg/day (no.=1). T4 was added in 6 patients. Normalisation of serum T4 occurred at 4 months (1- 9) and TSH at 7 months (3-24) after start of therapy. Treatment was discontinued after a minimum of 2 yr in 11 patients, relapse occurring in 9. Median duration of total therapy was 58 months (18-132). During adolescence, 4 patients had curative therapy by surgery (no.=2) or radioiodine (no.=2). In conclusion, disturbance of growth, behavioral difficulties and infrequent spontaneous remission are key features of Graves' disease in early childhood.

An optimal treatment for pediatric Graves' disease is radioiodine

CONTEXT

Antithyroid medications, surgery, and radioactive iodine have been used for more than five decades for the treatment of hyperthyroidism due to Graves' disease in children, adolescents, and adults. Despite the widespread use of these different approaches, controversy still exists relative to the merits of each treatment, especially regarding the use of radioactive iodine.

OBJECTIVE

The objective of the study was to address the risk and benefits of (131)I therapy, as compared with other treatment approaches. POSITION: Long-term, spontaneous remission of Graves' disease occurs in less than 30% of children. Thus, the majority of children with Graves' disease will need definitive, curative therapy. There is little evidence that use of antithyroid medications beyond 1 or 2 yr increases the likelihood of spontaneous, long-term remission. Although the use of antithyroid medications is standard practice, the use of antithyroid medications involves definite risks. When used at sufficient doses, radioactive iodine is an effective cure for Graves' disease and is associated with few acute side effects. Potential long-term adverse side effects, including thyroid cancer and genetic damage, have yet to be observed in individuals treated as children or adolescents with (131)I.

CONCLUSION

Properly administered, radioactive iodine remains an ideal form of treatment for Graves' disease in the pediatric population. Because of the increased risk of thyroid cancer associated with low-dose thyroid irradiation in children, larger, rather than smaller, doses of (131)I should be given.

Hypocalcaemia following therapy of thyrotoxicosis in an infant

A 2-mo-old infant born to a mother with Graves' disease and having symptoms of thyrotoxicosis was started on antithyroid drugs. Life-threatening hypocalcaemia requiring high-dose calcium infusions developed 1 mo after starting therapy. Serum alkaline phosphatase and paratharmone levels were elevated. This communication may serve to alert treating physicians about this rare complication in infants with thyrotoxicosis after initiation of antithyroid therapy.

CONCLUSION

Severe hypocalcaemia may follow initiation of antithyroid therapy in infants with thyrotoxicosis.

Influence of gender and pubertal stage at diagnosis on growth outcome in childhood thyrotoxicosis: results of a collaborative study

OBJECTIVE

To evaluate the influence of sex as well as pubertal stage at diagnosis on the growth outcome of childhood thyrotoxicosis.

DESIGN

Retrospective, collaborative study.

PATIENTS AND METHODS

Longitudinal auxological evaluation in 101 patients (M/F 23/78) for 4.7 +/- 3.1 years subdivided according to pubertal stage at diagnosis into prepubertal (group I) and pubertal (group II).

RESULTS

At diagnosis height and bone age (BA) standard deviation score (SDS) were positive both in girls and boys of groups I and II. In boys of group II, height SDS was significantly higher than in girls of the same group (P = 0.007) and in boys of group I (P = 0.026). During the follow-up, in group I, height SDS remained positive without significant differences between boys and girls, and in group II, height SDS remained significantly lower in girls than in boys. The age at onset of puberty and the age at menarche were within the normal range. Final height (FH) was within target height (TH) range in all groups The FH SDS and the height gain (FH-TH) were similar in girls and in boys in group I and significantly higher in boys than in girls (P < 0.05) in group II. The boys of group II showed a mean height gain significantly greater than that found in all the other groups.

CONCLUSIONS

Despite the advancement of BA at presentation, there were no adverse effects on subsequent growth and FH; the growth outcome seems to be better in boys than in girls in group II.

Hyperthyroidism

The clinical spectrum of hyperthyroidism varies from asymptomatic,subclinical hyperthyroidism to the life-threatening "thyroid storm". Hyperthyroidism is a common form of thyroid disease that mimics many of the common complaints in the emergency department. The diagnosis of hyperthyroidism is often challenging due to the multitude of physical and even psychiatric complaints. Recognition and treatment by emergency physicians of severe hyperthyroidism is critical and can be life saving.

[Graves' disease in children: management and review of 20 patients]

INTRODUCTION

Hyperthyroidism is a rare condition among children and the most common cause is Graves' disease. The best therapy for these patients continues to be debated.

PATIENTS AND METHODS

The medical records of 20 patients with Graves' hyperthyroidism who were treated between 1989 and 2003 were reviewed. Clinical symptoms, thyroid function, thyroid autoantibodies, thyroid imaging tests, first line therapy, disease or treatment-induced complications and the need for a secondary treatment option, as well as outcomes, were analyzed.

RESULTS

Age at diagnosis ranged from 5 to 16 years and there were more girls than boys (3:1). The most frequent symptom was hyperactivity (58 %). The most frequent sign was goiter (79 %). Thyroid-stimulating immunoglobulin antibodies were found in 90 % of the patients, at the beginning or during the course of the disease. All of the patients received antithyroid medication as first line therapy, but remission was achieved in just one patient. Surgical thyroidectomy was required in three patients, and two patients were treated with radioiodine.

CONCLUSION

Because few children achieve remission with medical therapy, other types of treatment (surgery or radioiodine) are often required. Although antithyroid drugs are considered the first choice for treatment in Europe, some authors advocate radioiodine as the treatment of choice.

Surgical treatment of Graves' disease in children

Thyroidectomy may be indicated in children with Graves' disease who have adverse reactions to antithyroid drugs or who relapse after antithyroid drug therapy. We investigated the characteristics of childhood Graves' disease from the standpoint of surgical outcome. Between 1989 and 1998, 1897 patients with Graves' disease underwent thyroidectomy and their thyroid function could be evaluated 2 to 3 years after thyroidectomy. The patients were divided into three groups according to age at thyroidectomy: 74 patients were 15 years old or less (children), 345 patients 16 to 20 years of age (adolescents), and 1478 patients 21 years of age or more (adults). The children included higher proportions of patients who had a large goiter (> 100 g), high thyrotropin-binding inhibitory immunoglobulin (TBII) level (> 50%), and small remnant thyroid (< 4 g). At 2 to 3 years after thyroidectomy, the overt recurrence rate of the children, adolescents, and adults was 9.5%, 4.9%, and 5%, respectively. The cumulative recurrence-free rate of the children, adolescents, and adults at 5 years after thyroidectomy was 82%, 90%, and 92%, respectively. Surgical complications were more frequently observed in children. Considering the aggressiveness of childhood Graves' disease, subtotal thyroidectomy with thyroid remnant less than 3 g is the procedure of choice for preventing recurrent hyperthyroidism.

Utilização do 131I no tratamento da doença de Basedow-Graves na infância e adolescência

Embora o diagnóstico da Doença de Graves (DG) na infância e adolescência seja relativamente fácil, seu tratamento ainda é controverso. Pode-se utilizar fármacos anti-tireoideanos (MMZ ou PTU), porém a incidência de efeitos adversos nessa faixa etária é maior que nos adultos e a taxa de remissão é baixa, mesmo com o uso prolongado. A cirurgia é pouco indicada como tratamento inicial, sendo realizada mais freqüentemente após recidiva do tratamento medicamentoso e/ou devido aos seus efeitos adversos. A utilização da radioiodoterapia na infância e adolescência vem crescendo. Com doses adequadas, ocorre o desenvolvimento de hipotireoidismo em cerca de 90% dos casos num período de 3 a 6 meses. Os dados iniciais sugerem que o tratamento em crianças acima de 5 anos não parece estar associado a maior risco de carcinoma de tireóide. A prevalência de efeitos adversos é menor que na cirurgia. Pacientes que apresentam fatores clínicos ou laboratoriais de pior prognóstico evolutivo podem ter seu tratamento medicamentoso encurtado, sendo a indicação da radioiodoterapia realizada mais precocemente.

[Treatment of Graves' disease: 300 cases]

OBJECTIVE

To try to select the best treatment among synthetic anti-thyroid agents, surgery and radioiodine in the case of Graves' disease.

METHOD

We present a retrospective study of therapeutic and progressive aspects of 300 cases of Graves' disease.

RESULTS

At the time of the diagnosis, the patients' mean age was of 38.17 years. Female sex predominated (70.7%). Medical treatment was prescribed in 25.7% of cases. Agranulocytosis occurred in one patient who died from septic shock. Surgery was performed in 29.3% of patients and 41% were treated with radioactive iodine. After a mean follow-up of 53.7 months, a progression towards euthyroidism was noted in 60, 22.7 and 21.7% of patients treated respectively with antithyroid drugs, surgery and radioiodine. Hypothyroidism was noted in around 40% of cases, 57.8% of which were treated surgically. Recurrent hyperthyroidism is more frequent with antithyroid drugs.

CONCLUSION

Medical treatment increases the risk of relapse. It is therefore preferable to apply radical treatments in order to obtain permanent remission from hyperthyroidism.

A case report of neonatal thyrotoxicosis due to maternal autoimmune hyperthyroidism

A case of neonatal thyrotoxicosis secondary to maternal autoimmune hyperthyroidism is reported in an infant born at 34 weeks gestation who presented with tachycardia, jitteriness, diarrhea, and a small goiter. Propranolol and oxygen were used to treat high-output cardiac failure and transient persistent pulmonary hypertension. The infant's response to propylthiouracil therapy, gradual resolution of cardiac and systemic symptoms, and normaliziation of thyroid studies are described. Thyroid physiology and function and the special considerations in a premature infant are reviewed. An overview of maternal autoimmune hyperthyroidism and the implications for the developing fetus and neonate are presented. The risk factors for, and clinical presentation of, hyperthyroidism are outlined and treatment strategies highlighted. The nursing care of infants with hyperthyroidism is carefully described with an emphasis on the surveillance for and management of multisystem manifestations.

Graves' disease in pregnancy: prospective evaluation of a selective invasive treatment protocol

OBJECTIVE

Graves' disease in pregnancy carries a risk of fetal thyrotoxicosis from the transplacental transfer of thyroid-stimulating antibodies or fetal hypothyroidism from transplacental transfer of antithyroid drugs and thyroid-blocking antibodies.

STUDY DESIGN

From 1991 through 2002, all pregnant women with Graves' disease underwent follow-up evaluations that included serial thyroid-stimulating antibody level, thyroid function, and ultrasound examinations. Umbilical blood sampling was recommended if the thyroid-stimulating antibody level was abnormally high or if fetal tachycardia, goiter, intrauterine growth retardation, or hydrops were present. For fetal hyperthyroidism, the mother received antithyroid drugs; for fetal hypothyroidism, maternal antithyroid treatment was reduced, and thyroxine was injected into the amniotic sac.

RESULTS

Of 40000 deliveries, 24 pregnancies (26 fetuses) occurred in 18 women with Graves' disease. Nine of 14 mothers with positive findings elected umbilical blood sampling. In 4 of the mothers, the results were normal. Hyperthyroidism and hypothyroidism were diagnosed in 2 and 3 fetuses, respectively. All the fetuses were treated successfully by the protocol with up to four repeated umbilical blood samplings. No complications were recorded in any of the 20 umbilical blood sampling. In the 5 patients who had only elevated thyroid-stimulating antibody levels and who did not elect umbilical blood sampling, sonographic findings remained normal up to term, and the newborn infants were normal. One of 12 children (in whose case we did not recommend umbilical blood sampling) was born with transient hypothyroidism caused by maternal propylthiouracil treatment. All children, whose cases were followed for up to 9 years, are normal.

CONCLUSION

In women with Graves' disease, umbilical blood sampling in selected cases may improve the control of fetal thyroid function.

Graves disease in childhood: a review of the options for diagnosis and treatment

While diagnosing Graves disease in childhood and adolescence does not usually present specific problems, the treatment of hyperthyroidism is still controversial. In particular, with regard to the use of radioiodine therapy, strategies vary between many European and North American pediatric endocrinology centers. After the diagnosis is made, antithyroid drug treatment with methimazole (thiamazole), carbimazole, or propylthiouracil should be performed with caution, in particular, because of severe adverse effects, such as agranulocytosis or hepatitis, that are found in up to 1% of patients. Antithyroid drug treatment should not be continued long-term, particularly since definitive remission cannot be expected in more than 30-40% of patients. In contrast, the risk of severe adverse effects is still present, and the risk of thyroid carcinoma increases with time and appears to be considerably higher than after radioiodine treatment. To a great extent, the success of surgery depends on the skills of a trained surgeon. The question of whether to perform total or subtotal thyroidectomy is yet to be resolved. Surgery should be considered in patients with a large thyroid gland (>80g), severe ophthalmopathy, and a lack of remission on antithyroid drug treatment. Success rates have increased to up to 97%, while severe adverse effects (laryngeal nerve palsy, hypoparathyroidism) occur in approximately 4% of patients. Mortality is below 0.1%. Radioiodine treatment in children >5 years of age does not appear to be associated with an increased risk of thyroid carcinoma; however, long-term data are lacking. Compared with the surgical approach, success rates are lower, particularly if low doses of radioiodine are used. In general, adverse effects are less prevalent than in patients who have undergone surgery.

Influence of iodine-131 dose on the outcome of hyperthyroidism in children

OBJECTIVES

Iodine-131 is an effective treatment for Graves' hyperthyroidism in children and adults. Yet the responses to treatment as related to iodine-131 dose in children are not well-defined. The objective of this study was to examine the relationship between the dose of iodine-131 in children with hyperthyroidism and thyroid status 1 year after treatment.

METHODS

We examined the outcome of iodine-131 treatment in children and adolescents with Graves' disease, as related to dose. Three iodine-131 doses were compared: 72 to 108 Gy (80-120 microCi/g), 180 to 225 Gy (200-250 microCi/g), and 270 to 364 Gy (300-405 microCi/g) in 31 patients ranging in age from 7 to 18 years old. Thyroid status was assessed >1 year after therapy.

RESULTS

We found that doses of 100 Gy (110 microCi/g), 200 Gy (220 microCi/g), and 300 Gy (330 microCi/g) resulted in hypothyroidism in 50%, 70%, and 95% of treated individuals, respectively. These data show that to insure ablation of thyroid tissue doses, >270 Gy (300 microCi/g) is needed, especially when the thyroid is large.

Evaluation and management of a solitary thyroid nodule in a child

Although an uncommon clinical entity, a pediatric patient with a solitary thyroid nodule requires a thorough assessment because of the increased incidence of thyroid carcinoma in this population. In the future, one may expect the widespread clinical use of genetic markers in identifying children, who are at risk for, or who have developed, thyroid carcinomas, with the hopes that these molecular markers will lead to the prevention, or earlier detection and cure, of these malignancies.

Inflammatory thyroid disorders

Inflammatory thyroid disorders encompass a broad spectrum of diseases that are generally self-limited, and relatively easy to diagnose and manage. Autoimmune subtypes are by far the most commonly encountered diagnoses and create the most confusion because of simultaneous overlap and the potential for interconversion among the subtypes. The otolaryngologist will frequently see these disorders and provide valued consultative care and surgical intervention as needed.

Current controversies in the management of pediatric patients with well-differentiated nonmedullary thyroid cancer: a review

Current treatment strategies for pediatric patients with nonmedullary, well-differentiated thyroid carcinoma (WDTC) are derived from single-institution clinical cohorts, reports of extensive personal experience, and extrapolation of several common therapeutic practices for this tumor in adults. Because pediatric WDTC is an uncommon malignancy, the issues of its optimal initial and subsequent long-term treatment and follow-up remain controversial. Pediatric patients with WDTC can be divided into two groups: children younger than 10 years of age and teenagers/adolescents between 10 and 18 years of age because these groups have different recurrence and mortality rates. We hereby present our views and interpret them in the light of the pertinent literature. Our recommendations on treatment strategies are more relevant for younger children. After midpuberty, optimal treatment is adequately addressed in the relevant literature on adults. For the majority of patients, total/near-total thyroidectomy is currently recommended as the standard initial therapy for WDTC. This is commonly followed by administration of radioiodine (RAI; (131)I) therapy to destroy residual normal thyroid tissue (remnant). Routine (131)I remnant ablation has been shown to: (1). decrease the risk of local recurrences, (2) increase the sensitivity of subsequent diagnostic RAI whole-body scanning (WBS), and (3) render serum thyroglobulin (Tg) a highly sensitive marker for recurrent/residual disease during long-term follow-up. We recognize that the above practices are not universally adhered to in children and adolescents, because the risk stratification and intensity of applied therapeutic measures are influenced by institutional traditions and personal experience. In our view, aggressive initial management, followed by evaluations at regular intervals after thyroidectomy and (131)I remnant ablation, in conjunction with long-term thyroid hormone suppressive therapy (THST), result in decreased recurrence rates in pediatric patients with WDTC. Follow-up examinations should include a diagnostic RAI ((131)I or (123)I) WBS and measurement of serum Tg, both performed under conditions of TSH stimulation, as well as neck ultrasonography (US). Our strategy is corroborated by data from retrospective clinical cohort studies. In this malignancy, no evidence of disease (NED) status can be defined as the combination of a negative diagnostic WBS and the presence of undetectable or low serum Tg levels, both tested under TSH stimulation. These findings should be accompanied by the absence of anatomically definable disease by standard imaging modalities, e.g., neck US or chest computed tomography (CT). Although the long-term survival rates are good overall in this disease, selected patients may require further surgery or (131)I therapy for the eradication or clinical control of metastases. Finally, and importantly, because the duration of follow-up is lifelong, the care of children with prior diagnosis of WDTC should be transferred to an adult endocrinologist after they reach adulthood, even if they have achieved NED status by that time.