Background: Paediatric thyrotoxicosis is both rarer and more severe than in adulthood, rendering management difficult, and often unsatisfactory.
Objective: To review outcome in a geographically defined area between 1989 and 2013; hence to develop an algorithm for improved clinical care.
Method: Retrospective case note review plus questionnaire to family doctor requesting update. Graves disease (GD) was defined as positive TSH-R-ab (TRAB+ve)±exophthalmos; Hashimotos (HT) as positive TPO-ab but negative TRAB+no eye signs. Treatment with antithyroid drugs (ATD) carbimazole (CBZ)±propythiouracil (PTU), total or subtotal thyroidectomy or radioiodine (RI) was recorded. Syndromic disorders (including Downs) were excluded.
Results: 67 patients (59F:8M) were identified,median (range) age at diagnosis 10.4 (2.915.8) years (diabetes mellitus in three) GD in 47, HT in 13, data insufficient in seven. Median (range) duration of ATD was 4.5 (0.316.2) years and was initially with dose titration in 46 patients and block and replace in 21. No deaths or liver disease occurred but 16 patients changed from CBZ to PTU due to rash/neutropenia. Of 35 patients who stopped ATD for possible remission after 4.5 (1.58.6) years, 17 remitted (eight GD:nine HT), six within and 11 after 3 years of treatment while 13 relapsed (12 GD:one HT); outcome unknown in five. RI 500 (250500) MBq was given to 18 patients after 5.37 (0.712.3) years of ATD for relapse (5), poor control/compliance (10), or electively (3) with subsequent hypothyroidism in all except one girl aged 10 years who showed persisting hyperthyroidism requiring ATD. Surgery was performed in 15 patients aged 11.64 (621) years for relapse with ATD (3), poor control/compliance (9), elective Rx(3), followed by hypothyroidism (7), relapse requiring RI (1), return to ATD (2), euthyroid (2), and unknown (3). One patient developed hypoparathyroidism after surgery.
Conclusion: HT is more likely to remit with ATD than GD. Time to remission with GD is variable with no evidence to support trying patients off treatment after an arbitrary interval (e.g. 3 years). We recommend i) rigorous patient education; ii) ascertainment of TPO and TRAB status at diagnosis; iii) dose titration rather than block and replace to permit continuous evaluation of thyroid status and possible remission; and iv) recourse to second line treatment (RI or total thyroidectomy) sooner rather than later when adherence to ATD becomes a struggle for the family.
01 Oct 2015 - 03 Oct 2015