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Good Morning and Welcome Applicants!. January 14, 2011. Thyrotoxicosis. Most common cause in children Graves Disease >95% Other Causes Early phase Hashimoto Hyperfunctioning thyroid nodule Pituitary resistance to thyroxine TSH secreting adenoma Factitious hyperthyroidism .

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thyrotoxicosis
Thyrotoxicosis
  • Most common cause in children
    • Graves Disease
    • >95%
  • Other Causes
    • Early phase Hashimoto
    • Hyperfunctioning thyroid nodule
    • Pituitary resistance to thyroxine
    • TSH secreting adenoma
    • Factitious hyperthyroidism
graves disease
Graves Disease
  • Autoimmune
    • HLA – A1, B8 & DR3
  • 0.02% of children
  • Positive FH
  • Peak incidence
    • 11-15 years
  • Males vs Females
    • Females 6-8x greater
graves disease1
Graves Disease
  • Antibodies
    • TSH receptor
    • Stimulating
  • Other autoimmune disorders
    • Type 1 DM
    • Hypoparathyroidism
    • Addison Disease
    • Myasthenia, periodic paralysis, vitiligo, pernicious anemia
hyperthyroidism
Hyperthyroidism
  • CV
    • Tachycardia
    • Palpitations
    • Widened pulse pressure
    • Overactive precordium
hyperthyroidism1
Hyperthyroidism
  • Neuromuscular
    • Tremors
    • Shortened DTR relaxation
    • Fatigue
    • Proximal muscle weakness
hyperthyroidism2
Hyperthyroidism
  • Other
    • Increased appetite
      • Weight loss
    • Diarrhea
    • Increased perspiration
    • Warmth
    • Heat intolerance
    • Tall
    • Menstrual irregularities
hyperthyroidism3
Hyperthyroidism
  • Behavioral disturbances
    • More common in children
    • Decreased attention span
    • Difficulty concentrating
    • Emotional lability
    • Hyperactivity
    • Difficulty sleeping
    • Nervousness
graves disease pe
Graves Disease PE
  • Thyroid
    • Diffusely enlarged
  • Eyes
    • Proptosis or exophthalmos
    • Findings less common in children
graves disease pe1
Graves Disease PE
  • Extremities
    • Pretibialmyxedema
    • Rare in children
lab values
Lab Values
  • Free T4
    • Elevated
  • TSH
    • Depressed or undetectable
  • Thyroid receptor antibodies
treatment
Treatment
  • Antithyroid medications
  • Radioiodine ablation
  • Surgical thyroidectomy
  • Don’t forget symptomatic treatment
antithyroid medications
Antithyroid Medications
  • Reduce hormone production and block its effect peripherally
  • Usually 1st line therapy
  • Prolonged treatment
    • 2-5y
  • May be stopped after prolonged euthyroidism
  • 30-40% long term remission
antithyroid medications1
Antithyroid Medications
  • Propylthiouracil
    • Also blocks conversion of T4 to T3
    • Preferred in pregnancy
  • Methimazole
    • Longer half life
antithyroid medications2
Antithyroid Medications
  • Side effects
    • Pruriticpapular or urticarial rash
    • Joint pain or stiffness
    • Hair loss
    • Nausea
    • Headache
    • Transient granulocytopenia
radioiodine ablation
Radioiodine Ablation
  • Oral iodine-131
  • Concentrates in thyroid
  • Induces cell death
  • Cure rate >90%
radioiodine ablation1
Radioiodine Ablation
  • Risks
    • 40-80% hypothyroidism
    • Children
      • Leukemia
      • Thyroid cancer
      • Genetic damage
subtotal or total thyroidectomy
Subtotal orTotal Thyroidectomy
  • Patient population
    • Fail initial medical therapy
    • Relapse after cessation of medical therapy
    • Drug reactions
    • Large goiters
    • Severe ophthalmopathy
subtotal or total thyroidectomy1
Subtotal orTotal Thyroidectomy
  • Cure rate 90%
  • Risks
    • Complex surgical procedure
    • Hypoparathyroidism
    • Recurrent laryngeal nerve injury
    • Hypothyroidism
hyperthyroidism4
Hyperthyroidism
  • Refer to pediatric endocrinologist
    • Underlying cause
    • Counseling on treatment options
  • Lifelong follow up is necessary
ad