Unusual Presentations of
Hypothyroidism in Children
Shannon Huelsman
April 12, 2007
Hypothyroidism: A decrease in T3
and T4
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Thyroid Axis
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Classifications
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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).
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Primary= Dysfunction of
the Thyroid gland
Secondary= Dysfunction
of the Pituitary
Tertiary= Dysfunction at
the Hypothalmus level
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Hypothyroidism: Facts
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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.
Hypothyroidism- Unusual Presentations
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Finding the Zebra’s!
Hypothyroidism and Renal Failure
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Multiple case reports have shown:
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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:
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Untreated primary hypothyroidism in children is associated with a
40% reduction in renal function.
Hypothyroidism, Vaginal Bleeding,
and Ovarian Cysts
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Case reports have described:
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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.
Hypothyroidism and Type 1
Diabetes Mellitus
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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
2- Thyroid Peroxidase:
•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 350%.
•As a screening tool: 67% Positive
predictive value and a 90% negative
predictive value.
•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.
So why is this important???
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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 subclinical level).
Bottom line: A proper diagnosis lead to improvement in symptoms,
it will also prevent unnecessary medical treatment, surgery, and
expenses
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Any Questions???