Pediatric Hyperthyroidism Clinical Presentation

Updated: Nov 03, 2015
  • Author: Sunil Kumar Sinha, MD; Chief Editor: Stephen Kemp, MD, PhD  more...
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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


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