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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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Good morning and welcome applicants

Good Morning andWelcome Applicants!

January 14, 2011


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