Graves Disease, Hyperthyroidism
also see Maternal hyperthyroid and the newborn, Thyroid nodules

• The most common cause of hyperthyroidism in adolescents is Graves disease:
• goiter
• muscle weakness and tremor
• weight loss despite an increase in appetite
• nervousness
• sleep disturbances.
• wide range of menstrual changes can occur, including amenorrhea, oligomenorrhea, or dysfunctional uterine bleeding.
• Interestingly, eye changes, such as exophthalmos, ptosis, and lid lag, are less severe than in adults who have hyperthyroidism.
• Cutaneous manifestations are variable and can affect the hair, nails, and skin. 

Diagnosis

• Most cases of hyperthyroidism can be confirmed by obtaining TSH and thyroxine (T4)
• TSH will be low in all cases of Graves disease. I
• in addition, thyroid antibodies can be measured and will be present.
• Thyroid scans usually are not indicated in an adolescent unless a nodule is palpated, but if ordered, they will reveal elevated uptake.
• Thyroid Lab Scenarios

Therapy

• Therapy for hyperthyroidism includes medical treatment, ablation with I131, and surgery.
• The most appropriate initial treatment for adolescents is oral therapy with methimazole, carbimazole, or propylthiouracil. I
• In adolescents, methimazole often is preferred because maintenance doses can be administered once daily.
• Minor complications of medical therapy include pruritus, fever, rash, and urticaria.
• Suppressive medical therapy is recommended for at least 12 to 24 months before the drug gradually is discontinued.
• The patient then requires lifelong monitoring for relapse or the development of hypothyroidism.
• If a relapse occurs or the patient is not well controlled on oral therapy, ablative therapy with I131 may be indicated.
• Ablative therapy is highly successful, but its use in adolescents and children is controversial because of the theoretic long-term risks of radiation exposure. The appropriate radiation dosage may vary among institutions. Regardless, all treated individuals require close follow-up for the development of hypothyroidism. 
• Surgical treatment for hyperthyroidism is reserved for those individuals who do not respond to medical therapy, refuse oral medication, or have especially large goiters. Complications include hypothyroidism, hypoparathyroidism, and paralysis of the recurrent  laryngeal nerve.
  Oral thyroxine may be necessary in a patient who has developed hypothyroidism following ablative therapy or surgery. It is not appropriate for the initial management of hyperthyroidism. Observation and re-evaluation are inappropriate treatment for the adolescent described in the vignette, who is symptomatic.

References (and further outline information below)
Neinstein LS, Kaufman FR, Ratner F. Thyroid disease in adolescents
(hyperthyroidism). In: Neinstein LS, ed. Adolescent Health Care: A
Practical Guide. 3rd ed. Baltimore, Md: Williams & Wilkins;
1996:200-204
Sperling MA. Disorders of the thyroid in children. In: Pediatric
Endocrinology. Philadelphia, Pa: WB Saunders Co; 1996:181-183

• diffuse toxic goiter (Grave’s disease)

1. most common cause in children
2. caused by thyrotropin receptor-stimulating antibodies (analogous to TSH)
3. treat with thionamides (e.g., Tapazole, PTU), radioactive iodine, and/or surgery

• TSH receptor activating mutations

• thyroid adenomas (e.g., McCune Albright syndrome)

• toxic uninodular goiter (Plummer disease)

• hyperfunctioning thyroid carcinoma

• subacute thyroiditis

• acute suppurative thyroiditis

• TSH secreting pituitary tumors

Symptoms and signs:

• emotional disturbances

• motor hyperactivity

• tremor

• voracious appetite combined with loss of or no increase in weight

• goiter (variable in size)

• exophthalmos

• lagging of the upper eyelid as the eye looks downward, impairment of convergence, and/or retraction of the upper eyelid and infrequent blinking

• smooth and flushed skin

• excessive sweating

• tachycardia, palpitations, dyspnea

• increase in systolic blood pressure and the pulse pressure

CHLA Board Review 2005