Pediatric Hyperthyroidism Clinical Presentation

  • Author: Robert J Ferry Jr, MD; Chief Editor: Stephen Kemp, MD, PhD   more...
 
Updated: Nov 3, 2011
 

History

In children and adolescents, the symptoms of Graves disease, such as hyperthyroidism, may appear insidiously over months. Early diagnosis requires a high degree of suspicion.

The common symptoms of hyperactivity, nervousness, and emotional lability are often attributed to other causes, most frequently attention deficit hyperactivity disorder (ADHD). Alterations in mental status may be seen in almost one half of all patients with thyroid dysfunction.

Deterioration of behavior and school performance in a child who previously did well may be the earliest warning signal.

The combination of thyrotoxicosis and ophthalmopathy makes the diagnosis of Graves disease relatively straightforward. The reported incidence of ophthalmopathy in patients with Graves disease is 50-80%. Eye findings may occur months before or after the initial presentation of thyroid disease.

Other symptoms of Graves disease can include the following:

  • Weight loss (50%) despite excellent appetite (increased appetite in 60%)
  • Sweating (49%)
  • Hyperactivity (44%)
  • Heat intolerance (33%)
  • Palpitations (30%)
  • Fatigue (16%)
  • Diarrhea (13%)
  • Insomnia
  • Deterioration in handwriting
  • Menstrual irregularities
  • Muscle weakness manifested as exercise intolerance or difficulty climbing stairs
  • Eye symptoms, which may include pain or diplopia but are rarely severe in children
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Physical Examination

Patients with Graves disease present with diffuse, nontender, symmetric enlargement of the thyroid gland. Goiter is rarely the presenting complaint, but it is invariably present (99%); absence of a goiter makes the diagnosis of Graves disease subject to question.

A thyroid bruit caused by increased blood flow to the thyroid gland is detectable in approximately 53% of patients.

Cardiac examination may reveal tachycardia (82%) and wide pulse pressure (50%) or hypertension. Signs of congestive heart failure (CHF) are rare in pediatric patients with Graves disease beyond the neonatal period.

Patients may have a wide variety of eye findings, including the following:

  • Exophthalmos (proptosis) (66%), occasionally unilateral; however, severe ophthalmopathy is quite rare in children
  • Lid lag, lid retraction
  • Stare
  • Conjunctival injection
  • Chemosis
  • Periorbital edema
  • Ophthalmoplegia
  • Optic atrophy

Other physical findings include the following:

  • Smooth sweaty skin
  • Tremor or muscle fasciculations (61%)
  • Exaggerated deep-tendon reflexes (DTRs)
  • Proximal muscle weakness
  • Systemic hypertension
  • Accelerated growth and early epiphyseal closure (over time)
  • Graves dermopathy, or localized myxedema, which is exceedingly rare in children; if it occurs, it is likely to be noticed in the pretibial area
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Contributor Information and Disclosures
Author

Robert J Ferry Jr, MD  Professor and Chief, Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, University of Tennessee Health Science Center; Brigade Surgeon, 36th Sustainment Brigade, US Army; Adjunct Professor, Pediatric Surgery Department, King Saud University, Saudi Arabia

Robert J Ferry Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Diabetes Association, American Medical Association, Endocrine Society, Pediatric Endocrine Society, Society for Pediatric Research, and Texas Pediatric Society

Disclosure: Nutropin Speakers Bureau Honoraria Speaking and teaching; Genotropin Speakers Bureau Honoraria Speaking and teaching; Eli Lilly & Co. Grant/research funds Investigator; MacroGenics, Inc. Grant/research funds Investigator; Ipsen, S.A. (formerly Tercica, Inc.) Grant/research funds Investigator; NovoNordisk SA Grant/research funds Investigator; Diamyd Investigator

Coauthor(s)

Jonathan G Gold, MD  Associate Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University College of Human Medicine

Jonathan G Gold, MD is a member of the following medical societies: American Academy of Pediatrics and Council on Medical Student Education in Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD  Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) Professor and Chair, First Department of Pediatrics, Athens University Medical School, Aghia Sophia Children's Hospital, Greece; UNESCO Chair on Adolescent Health Care, University of Athens, Greece

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) is a member of the following medical societies: American Academy of Pediatrics, American College of Endocrinology, American College of Physicians, American Pediatric Society, American Society for Clinical Investigation, Association of American Physicians, Endocrine Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Cydney L Fenton, MD, FAAP Consulting Staff, Department of Pediatric Endocrinology, Children's Hospital Medical Center of Akron

Cydney L Fenton, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Diabetes Association, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society

Disclosure: Nothing to disclose.

Ab Sadeghi-Nejad, MD Chief, Division of Pediatric Endocrinology and Metabolism, Tufts Medical Center; Professor of Pediatrics, Tufts University School of Medicine

Ab Sadeghi-Nejad, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Pediatric Society, Endocrine Society, Massachusetts Medical Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Thomas A Wilson, MD Professor of Clinical Pediatrics, Chief and Program Director, Division of Pediatric Endocrinology, Department of Pediatrics, The School of Medicine at Stony Brook University Medical Center

Thomas A Wilson, MD is a member of the following medical societies: Endocrine Society, Pediatric Endocrine Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References

  1. Emiliano AB, Governale L, Parks M, Cooper DS. Shifts in Propylthiouracil and Methimazole Prescribing Practices: Antithyroid Drug Use in the United States from 1991 to 2008. J Clin Endocrinol Metab. Mar 24 2010;[Medline].

  2. Bartalena L, Baldeschi L, Dickinson AJ, et al. Consensus statement of the European group on Graves' orbitopathy (EUGOGO) on management of Graves' orbitopathy. Thyroid. 2008;18:333-46. [Medline].

  3. Bahn R. The EUGOGO consensus statement on the management of Graves' orbitopathy: equally applicable to North American clinicians and patients. Thyroid. 2008;18:281-2. [Medline].

  4. Yoshimura Noh J, Miyazaki N, et al. Evaluation of a new rapid and fully automated electrochemiluminescence immunoassay for thyrotropin receptor autoantibodies. Thyroid. 2008;18:1157-64. [Medline].

  5. [Guideline] US Preventative Services Task Force. Screening for thyroid disease: recommendation statement. Ann Intern Med. Jan 20 2004;140(2):125-7. [Medline].

  6. FDA MedWatch Safety Alerts for Human Medical Products. Propylthiouracil (PTU). Accessed: June 3, 2009. US Food and Drug Administration; [Full Text].

  7. Sisson JC, Freitas J, McDougall IR, et al. Radiation safety in the treatment of patients with thyroid diseases by radioiodine 131I : practice recommendations of the American Thyroid Association. Thyroid. Apr 2011;21(4):335-46. [Medline].

  8. [Guideline] Bahn Chair RS, Burch HB, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. Jun 2011;21(6):593-646. [Medline].

  9. [Guideline] Kahaly GJ, Bartalena L, Hegedüs L. The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective. Thyroid. Jun 2011;21(6):585-91. [Medline].

 
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Schematic representation of the negative/positive feedback system with respect to the hypothalamic-pituitary-thyroid axis. TRH = thyrotropin-releasing hormone; TSH = thyroid-stimulating hormone.
 
 
 
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