ESPE Abstracts

Introduction: Thyroid nodules are uncommon in the paediatric population, present in 5% of children but 35% of adults. However, up to 25% of paediatric nodules are malignant, compared to 5% in adults. It can be challenging to differentiate malignant nodularity from benign clinically, particularly in the presence of a thyroid disorder. We present two contrasting cases of adolescent girls with solitary thyroid nodules.

Case 1: A 13-year-old girl was referred to paediatric endocrinology with lethargy and headaches, with routine bloods which had uncovered biochemical hyperthyroidism (TSH 0.05 mU/l [0.4–4.0]; T4 10.5 pmol/l [9.0–25.0]; T3 elevated). She had a previous history of osteochondritis dissecans and a family history of hypothyroidism. On examination, she was euthyroid and a right-sided nodular goitre was palpable. Conservative management was planned as the patient was asymptomatic. An USS revealed a solitary, well-defined nodule (42×27×18 mm) in the right lobule which was isoechoic, heterogeneous, and contained internal vascularity. Reactive cervical nodes were noted. The nodule was ‘hot’ on scintigraphy, and FNAC indicated a Hürthle cell carcinoma. A repeat USS demonstrated increased vascularity suggesting the carcinoma was active. She was referred for a right hemi-thyroidectomy five months after she first presented.

Case 2: A previously well 14-year-old girl was referred to paediatrics by her GP with lethargy and constipation. Routine bloods demonstrated biochemical hypothyroidism (TSH: 10.5 mU/l [0.4–4.0], T4: 8.7 pmol/l [9.0–25.0]). A microcytic iron-deficiency anaemia was also noted and treated. Further symptoms included weekly panic attacks, frequent headaches and dizziness on exertion. On examination, a neck swelling was noted. Hashimoto’s thyroiditis was diagnosed and treated with levothyroxine. An USS showed a diffusely enlarged, heterogeneous thyroid gland the thyroid gland with a 15 mm hypoechoic nodule on the right, which was attributed to her Hashimoto’s thyroiditis. However, a further USS revealed the nodule contained peripheral vascularity, and FNAC was suspicious for follicular carcinoma. A diagnostic thyroid lobectomy found an irregular 17 mm nodule containing a 5 mm area of papillary microcarcinoma.

Discussion: The presentations of these two girls have a number of similarities and differences. While both girls presented with lethargy and a thyroid nodule, the initial diagnoses were distinct opposites. Both nodules were found to be malignant, but neither girl presented any ‘red flag’ symptoms clinically. US features – contrasting in these cases – can be ambiguous. The commonalities and differences of these presentations demonstrate that paediatric thyroid nodules must be thoroughly investigated, even in the context of a thyroid disorder.