Background: Hyperthyroidism due to Graves disease (GD) in children has a peak incidence between 10 and 15 years of age. It is a rare but serious disorder that if uncontrolled can have serious adverse outcomes on growth and development as well as health. The incidence of GD is believed to be between 0.1 and 3 per 100 000 children in the general population with a prevalence of 1/10 000 children in the US. GD is rare under the age of 5 years.
Objective and hypotheses: To determine the etiology of a 2 year old female presenting to the ER with 1 day history of fever and lip swelling, as well as diarrhea, emesis, throat pain, and tachycardia. Hyperactivity, difficulty sleeping and tremors had been noted more recently. Parent noted a lump the size of a golf ball appeared suddenly. Goiter appreciated on exam measuring 8 cm across and 5 cm vertically. I believed this to be acute, subacute, or autoimmune hyperthyroidism Hashitoxicosis vs Graves disease.
Method: To obtain thyroid function tests, thyroid antibodies, ESR and thyroid ultrasound and follow serial tfts longitudinally.
Results: TSH=0.005 μU/ml, FT4=>7.77 ng/dl (nl<1.6), TT3=651 ng/dl (High), TT4=27.2 μg/dl (4.512.0), TGAB<20 IU/ml, TPO AB=<6 IU/ml, TSI=252 (nl<140), ESR=6 (032). Thyroid ultrasound revealed enlarged thyroid gland bilaterally. Patient started on atenolol for symptom control and methimazole initially at 2.5 mg qd with peak dosing of 7.5 mg qd, with improving thyroid hormone values, however still remaining hyperthyroid until after 7 months of treatment, when she became euthyroid.
Conclusion: Given severe protracted hyperthyroidism and highly positive TSI antibodies, patient diagnosed with autoimmune Graves hyperthyroidism. To my knowledge, this is the youngest documented case of a female toddler with such severe autoimmune hyperthyroidism.
10 - 12 Sep 2016
European Society for Paediatric Endocrinology