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Key Features

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Essentials of Diagnosis
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  • Nervousness, emotional lability, hyperactivity, fatigue, tremor, palpitations, excessive appetite, weight loss, increased perspiration, and heat intolerance

  • Goiter, exophthalmos, tachycardia, widened pulse pressure, systolic hypertension, weakness, and smooth, moist, warm skin

  • Thyroid-stimulating hormone (TSH) is suppressed

  • Thyroid hormone levels (T4, FT4, T3, T3 resin uptake [T3RU]) are elevated

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General Considerations
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  • In children, most cases are due to Graves disease, caused by antibodies directed at the TSH receptor that stimulate thyroid hormone production

  • Other causes include

    • Thyroiditis (acute, subacute, or chronic)

    • Autonomous functioning thyroid nodules

    • Tumors producing TSH

    • McCune-Albright syndrome

    • Exogenous thyroid hormone excess

    • Acute iodine exposure

  • More common in females than males

  • When it occurs in children, it usually develops during adolescence

  • Course tends to be cyclic, with spontaneous remissions and exacerbations

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Clinical Findings

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  • Symptoms include poor concentration, hyperactivity, fatigue, emotional labiality, personality disturbance/unmasking of underlying psychosis, insomnia, weight loss (despite increased appetite), palpitations, heat intolerance, increased perspiration, increased stool frequency, polyuria, and irregular menses

  • Signs include tachycardia, systolic hypertension, increased pulse pressure, tremor, proximal muscle weakness, and moist, warm, skin; accelerated growth and development may occur

  • Thyroid storm

    • Rare

    • Characterized by fever, cardiac failure, emesis, and delirium that can result in coma or death

  • Graves disease

    • Most cases are associated with a diffuse firm goiter

    • A thyroid bruit and thrill may be present

    • Many cases are associated with exophthalmos

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Diagnosis

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Laboratory Findings
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  • TSH is suppressed

  • T4, FT4, T3, and free T3 (FT3) are elevated except in rare cases in which only the serum T3 is elevated (T3 thyrotoxicosis)

  • The presence of thyroid-stimulating immunoglobulin (TSI) or thyroid eye disease confirms the diagnosis of Graves disease

  • TSH receptor–binding antibodies (TRaB) are usually elevated

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Imaging
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  • Radioactive iodine uptake by the thyroid

    • Increased in Graves disease

    • Decreased in subacute and chronic thyroiditis

  • An autonomous hyperfunctioning nodule takes up iodine and appears as a "hot nodule" while the surrounding tissue has decreased iodine uptake

  • In children with hyperthyroidism, bone age may be advanced

  • In infants, accelerated skeletal maturation may be associated with premature fusion of the cranial sutures

  • Long-standing hyperthyroidism causes osteoporosis

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Treatment

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General Measures
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  • Strenuous physical activity should be avoided in untreated hyperthyroidism

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Medical
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  • β-Adrenergic blocking agents

    • Can rapidly ameliorate symptoms

    • Indicated in severe disease with tachycardia and hypertension

    • β1-Specific agents such as atenolol are preferred because they are more cardioselective

    • Propranolol also decreases conversion of T4 to active T3, so is preferred in severe cases/thyrotoxicosis

  • Antithyroid agents (methimazole)

    • Frequently used in the initial treatment of childhood hyperthyroidism

    • Usually take a few weeks ...

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