Thyroid Gland Diseases

in Children

PEDIATRIC DEPARTMENT
MEDICAL FACULTY
TARUMANAGARA UNIVERSITY
Functional condition of
Thyroid influence may be as

 Euthyroidism
 Hypothyroidism
 hyperthyroidism
Нypothyroidism

 Hypothyroidism - syndrome with

particular or total deficiency T3 and T4
or theirs acts to target cells
Classification of
hypothyroidism
Disturbances
 PRIMARY - defects of biosynthesis of
T3, T4 due to pathology of thyroid
gland
 SECONDARY - decreasing T3, T4 due
to deficiency of TSH (pituitary) or TRH
(hypothalamus) or Resistance of
receptors for T3, T4
Classification of
hypothyroidism
Onset
Congenital
Acquired (rare)
Classification of
hypothyroidism
Clinic & biologic data
 Latent (subclinical) T3 -N, T4 –N,
TSH > 10 mU/l
 Manifestation of disease due to ↓ T4 (at
first) & ↓ T3
 Complicate
ETIOLOGY OF CONGENITAL
HYPOTHYROIDISM
 Primary hypothyroidism Thyroid
dysgenesis (aplasia, hypoplasia, or ectopic
gland)
 Inborn error of thyroid hormone synthesis,
secretion, or utilization
 Maternal goitrogen ingestion or radioactive
iodine treatment
 Iodine deficiency (endemic goiter)
 Autoimmune thyroiditis
ETIOLOGY OF CONGENITAL
HYPOTHYROIDISM (c’d)
 Hypothalamic or pituitary
hypothyroidism
 Pituitary aplasia
 Septo-optic dysplasia
 PIT1 mutation (deficiency TSH, GH, Prol
 PROP-1 mutation (deficiency TSH, GH,
Prol,Lh,FSH,ACTH)
 Thyrotropin unresponsiveness
SYMPTOMS OF CONGENITAL
HYPOTHYROIDISM
 There is a tendency towards prolonged
gestation with 1/3 of pregnancies
lasting 42 weeks or more
 Prolonged jaundice
 Lethargy
 Constipation
 Feeding problems
 Cold to touch
SIGNS OF CONGENITAL
HYPOTHYROIDISM

Skin mottling and Dry skin

Umbilical hernia and Distended abdomen
Jaundice
Macroglossia
Large fontanels
Wide sutures
Hoarse cry
Muscle Hypotonia
Slow reflexes
Minority of CH
 Puffy myxedematous face
 Depressed nasal bridge with hypertelorism
 Large protruding tongue with an open mouth
 Cold, motted skin
 Short neck
 Palpebral fissures are narrow
 Short fingers
 Fat deposits between neck and shoulders
 Hiar is coarse, brittle and scanty
 Hiarline reaches far down on the forehead
DIAGNOSTIC STUDIES IN
HYPOTHYROIDISM

Thyroid scan – 99mTc or 123 IT3 resin

uptake
Bone age
TSH !!!
Free T4 – if hypothalamic- pituitary
hypothyroidism suspected
TBG – if TBG deficiency suspected
Anti-thyroid antibodies – if history of
maternal thyroiditis
Biochemical hallmarks of CH
 Low serum T4 and T3 with evaluated
TSH (primary)
 T3 –normal, T4 ↓- severe or
longstanding
 T4 –normal but TSH is elevated –
compensative CH, transient or
subclinical
 T4↓ but TSH normal- congenital TBG-
deficiency or hypothalamic-pituitary
hypothyrodism
Biochemical hallmarks of CH
Other:
 Elevated serum cholesterol

 Elevated creatinphosphokinase

 Hyponatriemia
Instrumental data
 Slightly decrease heart rate and
amplitude of R wave (ECG)
 Increase projection period, left
ventricular wall diameter, decrease LV
chamber size and decrease cardiac
output (EchoCG)
 Low-amplitude diffuse slowing (EEG)
Treatment L-thyroxin

 Preterm 8 – 10 μg/kg
 0-3 mo 10 – 15 μg/kg
 3-6 mo 8 – 10 μg/kg
 6-12 mo 6 – 8 μg/kg
 1-3 years 4 – 6 μg/kg
 3-10 years 3 – 4 μg/kg
 10-15 years 2 – 4 μg/kg
 > 15 years 2 – 3 μg/kg
ETIOLOGY OF ACQUIRED
HYPOTHYROIDISM
 Chronic lymphocytic (Hashimoto`s)
thyroiditis (CLT)
 Subacute thyroiditis (De Quervain`s)
 Goitrogens (iodide, thiouracil, etc.)
 Thyroidectomy or ablation following
radioactive iodine
 Infiltrative disease (e.g., cystinosis,
histiocytosis X)-systemic disease
ETIOLOGY OF ACQUIRED
HYPOTHYROIDISM (c’d)
 Hypothalamic or pituitary disease
 Congenital thyroid disorders, e.g., ectopia,
may not decompensate until later childhood
and thus may appear acquired
 Peripheral resistance to thyroid hormones,
including receptor defects
 Jatrogenic (propylthiouracil, methimazole,
iodides, lithium,amiodarone)
 Hemangiomas of the liver
SYMPTOMS OF ACQUIRED
HYPOTHYROIDISM
 Slow growth
 Puffiness
 Decreased appetite
 Constipation
 Swollen thyroid gland
 Lethargy
 Drop in school performance
 Cold intolerance
 Galactorrhea
 Menometrorrhagia
SIGNS OF ACQUIRED
HYPOTHYROIDISM

 Short stature
 Decreased growth velocity
 Increased upper to lower segment ratio
 Delayed dentition
 Myxedema or mildly overweight
 Goiter
SIGNS OF ACQUIRED
HYPOTHYROIDISM (c’d)
 Delayed reflex return
 Dull, placid expression
 Pale, thick, carotenemic, or cool skin
 Muscle pseudohypertrophy
 Delayed puberty or precocious puberty
 Treatment –same CH
Chronic thyroiditis Hashimoto
disease
Clinical presentation:
 goiter with euthyroidism

 Thoxic thyroiditis

 Hypothyroidism with or without

thyromegaly
 Dysphagia, pain or pressure sensation

in the neck, cough and headache have

been reported
Diagnosis Hashimoto disease

 T4 total and free, serum TSH

 Biopsy
 Antibodies test: antithyroglobulin
antibodies to thyroperoxidase
antimicrosomal test
Causes of thyrotoxicosis
 Congenital: transient, neonatal Graves’
disease
 Acquired: Graves’ disease
 Functional adenoma
 Thyroid cancer
 TSH-secreting pituitary tumor
 Iatrogenic
(Graves disease)
 Diffuse toxity goiter - autoimmune
pathology with prolonged elevation
T3 & T4 and enlargement of
Thyroid gland, and in 70% cases
with ophthalmopathy
Graves disease (symptoms)
 Hyperactivity, irritability, altered mood
 Fatigue, weakness
 Goiter
 Tachycardia and ↑ pul’s pressure
 Nervousness
Graves disease (symptoms)
 Palpitations
 Weight loss with ↑ appetite
 Heat intolerants, increase sweating
 Increased stool frequency
 Thirst and polyuria
 Oligomenorrea, loss of libido
Graves disease (signs)
 Sinus tachycardia, atrial fibrillation
 Tremor, hyperkinesis
 Warm, moist skin
 Palmar erythema, onycholysis
 Hair loss
 Muscle weakness & wasting
 Heart failure, psychosis (rare)
Graves disease
Ophthalmopathy
 A feeling of grittiness & discomfort in
the eye
 Retrobulbar pressure or pain
 Eyelid lag or retraction
 Periorbital edema, chemosis, scleral
injection
Graves disease
Ophthalmopathy (c’d)
 Proptosis
 Extraocular muscle dysfunction
 Exposure keratitis
 Optic neuropathy
Treatment of thyrotoxicosis
 Thionamids: mercasolyl 0.3-0.5 mg/kg
divided 2 -3 times – 14-21 days , than
supportive dose – 2.5-7.5 mg/daily 1
time
 Β ab (anaprilin) 1-2 mg/kg divided 3
times
 Euthyrosis – mercasolil 5-10 mg/daily
with L-thyroxin 25-50 μg/daily
 Surgical treatment
Thyroid storm (crisis)
 Sudden onset
 Fever
 Profuse diaphoresis
 Flushed warm skin
 Tachycardia
 Weakness, lethargy and confuson
 Coma
 Nausea, vomiting, diarrhea
 Enlarge liver, jaundice
Thyroid storm (crisis)
 NaJ 1-2 g daily IV immediately
 Propylthiouracil 200-300 mg every 6
hours by nasogastric tube
 Β ab (propranolol) 0.1 mg/kg IV or 4
mg/kg orally
 Dexamethasone 1-2 mg every 6 hours
 Supportive: correction of dehydratation,
antipyretics, digitalis to patients with
cardiac failure
GOOD LUCK!