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Unusual Presentations of Hypothyroidism in Children Shannon Huelsman April 12, 2007.

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Presentation on theme: "Unusual Presentations of Hypothyroidism in Children Shannon Huelsman April 12, 2007."— Presentation transcript:

1 Unusual Presentations of Hypothyroidism in Children Shannon Huelsman April 12, 2007

2 Hypothyroidism: A decrease in T3 and T4 Thyroid Axis Hypothalmus produces TRH. TRH stimulates the anterior pituitary, which releases TSH. TSH stimulates the Thyroid gland, which produces and releases thyroxine (T4) and triiodothyronine (T3). Classifications Primary= Dysfunction of the Thyroid gland Secondary= Dysfunction of the Pituitary Tertiary= Dysfunction at the Hypothalmus level

3 Hypothyroidism: Facts Primary hypothyroidism manifests as congenital, autoimmune thyroiditis (Hashimoto’s), or as a result of surgery, radiation, drugs, and toxins. Hypothyroidism affects 11 million adults and children. 1 in 4,000 infants have congenital hypothyroidism that is not due to iodine insufficiency. 1.2% of all school-aged children have autoimmune thyroiditis. 2 out of every 3 people with hypothyroidism are unaware of their disease status.

4 Hypothyroidism- Unusual Presentations Finding the Zebra’s!

5 Hypothyroidism and Renal Failure Multiple case reports have shown: – Children presenting with signs of renal failure (Elevated serum creatinine, decreased glomerular filtration rates) – Lab studies reviled that the children had elevated TSH and low T3 and T4. – The children were then placed on thyroxine therapy (Synthroid) – Thyroid function returned to normal – Serum creatinine levels and glomerular filtration rates also returned to normal. – Study Results: Untreated primary hypothyroidism in children is associated with a 40% reduction in renal function.

6 Hypothyroidism, Vaginal Bleeding, and Ovarian Cysts Case reports have described: – Young children presenting with cyclic vaginal bleeding and breast development without any pubic hair (a condition known as precocious puberty), as well as delayed bone age. – Ultrasounds showed at least one (if not many) ovarian cysts. – Lab studies reviled increased TSH and decreased T4. – The children were placed on thyroxine therapy, and within 3-6 months all symptoms were gone and the cysts were undetectable on ultrasound.

7 Hypothyroidism and Type 1 Diabetes Mellitus Well established connection exist between hypothyroidism and T1DM, however, many cases are sub-clinical in nature. Thus there is a need for different types of testing. Studies have suggested measuring: 1- Thyroid Autoantiboties One study reported that young diabetes have a higher prevelance of thyroid autoantibody than healthy controls. The occurrence of autoantibodies in patients with T1DM has been reported from 3- 50%. As a screening tool: 67% Positive predictive value and a 90% negative predictive value. 2- Thyroid Peroxidase: One study suggests that T1DM patients presenting with thyroid peroxidase antibodies have an increased risk of developing thyroid dysfunction Another study claims that if only thyroid peroxidase is used, up to 28% of subclinical cases would be missed.

8 So why is this important??? Low thyroid levels can hinder and alter normal childhood development due to the direct and indirect processes of the hypothalamus-pituitary-thyroid axis. Proper diagnosis of declining renal function and subsequent treatment leads to improvement of symptoms, it also allowed the children in question to be spared the rigors of renal failure treatment. In the case of ovarian cysts in precocious puberty, the recognition of hypothyroidism as the primary cause prevents surgical intervention. The link between autoimmune thyroid antibodies and the eventual development of autoimmune hypothyroidism allows providers to initiate treatment as soon as problems occur (which may at a sub- clinical level). Bottom line: A proper diagnosis lead to improvement in symptoms, it will also prevent unnecessary medical treatment, surgery, and expenses

9 References Al-Fifi S, Girgardin C,Sharma A, Rodd C. Moderate renal failure in association with prolonged acquired hypothyroidism in children. Acta Pediatr. 1999; 88:715-7 Bald M, Hauffa BP, Wingen AM. Hypothyroidism mimicking chronic renal failure in reflux nephropathy. Arch Dis Child. 2000; 83:251-2 Chattopadhyay A, Kumar V, Marulaiah M. Polycystic ovaries, precocious puberty and acquired hypothyroidism: the Van Wyk and Grumbach syndrome. J Pediatr Surg. 2003; 38: Chen CH, Tiu CM, Chou YH, Chen WYK, Hwang B, Niu DM. Congenital hypothyroidism with multiple ovarian cysts. Eur J Pediatr. 1999; 158: del-Río Camacho G, Tapia Ceballos L, Picazo Angelin B, Moreno Ruiz JA, Hortas Nieto ML, Romero Gonzáles J. Renal failure and acquired hypothyroidism. Pediatr Nephrol. 2003; 18:290-2 den Hollander JG, Wulkan RW, Mantel MJ, Berghout A. Correlation between severity of thyroid dysfunction and renal failure. Clinical Endocrinology. 2005; 62: Fernández-Castañer M, Molina A, López-Jiménez L, Gómez JM, Solier J. Clinical presntation and early course of type 1 diabetes in patients with and without thyroid autoimmunity. Diabetes Care. 1999; 22: Fischbach, Frances. A Manual of Laboratory and Diagnostic Tests, 7 th ed. Philadelphia: Lippincott Williams & Wilkins; Hansen D, Bennedbæk FN, Hansen LK, Høier-Madsen M, Jacobsen BB, and Hegedüs L. Thyroid function, morphology and autoimmunity in young patients with insulin-dependent diabetes mellitus. European Journal of Endocrinology. 1999; 140: Hansen D, Bennedbæk FN, Høier-Madsen M, Hegedüs L, and Jacobsen BB. A prospective study of thyroid function, morphology and autoimmunity in young patients with type 1 diabetes. European Journal of Endocrinology. 2003; 148: Kordonouri A, Deiss D, Danne T, Dorrow A, Bassir C, Grüters-Kieslich A. Predictivity of thyroid autoantibodies for the development of thyroid disorders in children and adolescents with type 1 diabetes. Diabetes Med. 2002; 19(6):

10 References Ladenson PW. Thyroid. In: Dale DC, editor-in-chief. ACP medicine: Volume 1. New York: WebMD; p Mattesone Porth C. Essentials of pathophysiology: concepts of altered health status. 2 nd ed. Philadelphia: Lippincott Williams & Wilkins: 2007 Mohn A, Michele S Di, Faricelli R, Martinotti S, Chiarelli F. Increased frequency of subclinical hypothyroidism and thyroid-associated antibodies in siblings of children and adolescents with type 1 diabetes mellitus. European Journal of Endocrinology. 2005; 153: Paydas S, Gokel Y. Different renal pathologies associated with hypothyroidism. Renal Failure. 2002; 24 (5): Phupong V, Aribarg A. Vaginal bleeding in a young girl due to primary hypothyroidism. Arch Gynecol Obstet. 2003; 268:217-8 Sims J, Haggerty M, Gale T. Hypothyroidism. In: Gale encyclopedia of children’s health. Detroit: Gale Group; Accessed online at 2/21/ Singh BM, Ammini AC, Kriplani A. Ovarian cyst in juvenile hypothyroidism. Arch Gynecol Obstet. 2005; 271: Steiger MJ, Watson AR, Morgan AG. Hypothyroidism and renal impairment. Journal of the Royal Society of Medicine Nov; 84 (11): Takeuchi K, Deguchi M, Takeshima Y, Maruo T. A case of multiple ovarian cysts in a prepubertal girl with severe hypothyroidism due to autoimmune thyroiditis. Int J Gynecol Cancer. 2004; 14: Umpierrez GE, Latif KA, Murphy MB, Lambeth HC, Stentnz F, Bush A, Kitabchi AE. Thyroid dysfunction in patients with type 1 diabetes. Diabetes Care. 2003; 26: Verhelst J, Berwaerts J, Marescau B, Abs R, Neels H, Mahler C, De Deyn PP. Serum creatine, creatinine, and other guanidine compounds in patients with thyroid dysfunction. Metabolism. 1997; 46(9): Warren RE, Perros P, Nyirenda MJ, Frier BM. Serum thyrotropin is a better predictor of future thyroid dysfunction than thyroid autoantibody status in biochemically euthyroid patients with diabetes: implications for screening. Thyroid. 2004; 14(10):

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