Graves Disease, Hyperthyroidism
also see Maternal hyperthyroid and the
- The most
common cause of hyperthyroidism in adolescents is Graves disease:
weakness and tremor
- weight loss
despite an increase in appetite
- 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.
manifestations are variable and can affect the hair, nails, and skin.
- 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.
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 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
adolescents, methimazole often is preferred because maintenance doses can be
administered once daily.
complications of medical therapy include pruritus, fever, rash, and urticaria.
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
- If a relapse
occurs or the patient is not well controlled on oral therapy, ablative therapy
with I131 may be indicated.
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.
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.
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;
Sperling MA. Disorders of the thyroid in children. In: Pediatric
Endocrinology. Philadelphia, Pa: WB Saunders Co; 1996:181-183
- most common cause in children
- caused by thyrotropin receptor-stimulating antibodies (analogous to TSH)
- treat with thionamides (e.g., Tapazole, PTU), radioactive iodine, and/or
TSH receptor activating mutations
thyroid adenomas (e.g., McCune Albright syndrome)
toxic uninodular goiter (Plummer disease)
hyperfunctioning thyroid carcinoma
acute suppurative thyroiditis
TSH secreting pituitary tumors
Symptoms and signs:
voracious appetite combined with loss of or no increase in
goiter (variable in size)
lagging of the upper eyelid as the eye looks downward,
impairment of convergence, and/or retraction of the upper eyelid and
smooth and flushed skin
tachycardia, palpitations, dyspnea
increase in systolic blood pressure and the pulse pressure
CHLA Board Review 2005