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Hypothyroidism

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Title: Hypothyroidism


1
Hypothyroidism
  • Eric Sherman
  • Pediatric Endo Fellow
  • Captain, USAF, MC

2
  • Who has ordered thyroid function tests (TFT)?
  • Who has made decisions based on the results?
  • Who has been confused by the results?
  • Who has referred someone to peds endo for
    abnormal TFTs?
  • Who follows patients with hypothyroidism without
    endocrine assistance?

3
Causes of hypothyroidism
  • Congenital 1 in 4000 live births
  • Acquired
  • Most common cause world wide??

4
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5
Causes of congenital hypothyroidism (CH)
  • Thyroid dysgenesis 14000
  • Thyroid dyshormonogenesis 140,000
  • Central hypothyroidism 1100,000
  • Transient hypothyroidism 140,000
  • Sperling

6
Signs/symptoms of CH
7
Signs/symptoms of CH
8
Newborn Screen
  • Mandatory in all 50 states
  • If performed before 24 hours, must be repeated at
    least one more time
  • Screening TSH DC
  • Screening FT4 VA, MD, overseas samples

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10
Positive newborn screen
  • Confirmatory serum TSH and FT4 ASAP
  • Call pediatric endocrinology
  • Start Synthroid at 10-15 micrograms/kg/day (50
    micrograms once daily in term infants)

11
Example of MD newborn screen
  • T4 10.8 (gt7.0)
  • T4 result is less than the 10th percentile for
    this run. A TSH has been performed on this
    specimen to complete the thyroid testing. TSH
    result is 74.9 uIU/mL (lt28.5 uIU/mL).
    Consultation with a pediatric endocrinologist ?
    and further serum thyroid studies are recommended.

12
How do you give Synthroid?
  • Pill crushed
  • Give with water or formula on a spoon, not in
    bottle or syringe
  • Avoid soy formula (absorption issues)
  • May double dose if previous days dose is missed

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14
Follow up
  • TSH and FT4 ever 1-2 months during year 1
  • Every 3-6 months from ages 1-3
  • Every 6-12 months from 3 until patient stops
    growing
  • Goal bring FT4 into high normal range as rapidly
    as possible (TSH may remain elevated in 10 of
    patients)

15
Why treat CH?
  • Average IQ 76 in pre newborn screen era
  • Untreated patients lose an average of 1-2 IQ
    points per month until age 2
  • 40 of untreated patients require special
    education in school
  • Data suggests that treatment should be initiated
    within 2 weeks (PREP says 3 months)

16
Long term consequences w/ treatment
  • Sensorineural hearing loss
  • Decline in verbal IQ
  • Head circumference 1 SD above the mean
  • Normal height and weight

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19
Goitrogens
  • Cabbage, kale and other cruciferous veggies
  • Soybeans
  • Animal fodder
  • Lithium
  • Amiodarone

20
Hashimotos (chronic lymphocytic) thyroiditis
  • Most common cause of goiter in children over 6
  • FgtM, family history in 30-40
  • More common in Downs and Turners syndrome

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23
Other S/S
  • Cold intolerance
  • Fatigue
  • Relative bradycardia
  • Unexpected weight gain (usually this is not the
    thyroids fault)
  • Goiter in 2/3 of cases

24
Associated illnesses
  • 25-30 of Type I diabetics have antibodies and
    10 have elevated TSH
  • Occasionally seen with celiac disease, JRA and
    IBD
  • Can be part of autoimmune syndromes like APS type
    1

25
Diagnosis
  • Elevated TSH and low or normal FT4
  • Anti-TPO and/or anti-TG antibodies in 90-95 of
    patients
  • TPO more sensitive and specific
  • Ultrasound not a part of routine screening

26
Treatment
  • Synthroid 100 micrograms/m2/day
  • Profoundly hypothyroid patients undergoing
    treatment can present with ???
  • Follow TSH to ensure adequate treatment

27
Untreated
  • Final adult height decreased
  • Progressive thyroid enlargement
  • Occasional significant pituitary enlargement
  • Increased risk of thyroid cancer (even in treated
    patients)

28
On a routine annual evaluation, a 13 year old
girl from the Midwest is found to have a
diffusely enlarged thyroid gland that is
approximately 3 times the normal size according
the World Health Organization criteria. She is
active, healthy, clinically euthyroid, and has no
other abnormalities on physical examination. The
family history discloses that two maternal aunts
and two cousins each were told that they had a
"goiter." Among the following, the most likely
cause of this patient's thyroid enlargement is
  • A. Adolescent goiter
  • B. Autoimmune thyroiditis
  • C. Familial thyroid dyshormonogenesis
  • D. Nutritional deficiency goiter
  • E. Thyroid neoplasia

29
On a routine annual evaluation, a 13 year old
girl from the Midwest is found to have a
diffusely enlarged thyroid gland that is
approximately 3 times the normal size according
the World Health Organization criteria. She is
active, healthy, clinically euthyroid, and has no
other abnormalities on physical examination. The
family history discloses that two maternal aunts
and two cousins each were told that they had a
"goiter." Among the following, the most likely
cause of this patient's thyroid enlargement is
  • A. Adolescent goiter
  • B. Autoimmune thyroiditis
  • C. Familial thyroid dyshormonogenesis
  • D. Nutritional deficiency goiter
  • E. Thyroid neoplasia

30
Among the following, the most sensitive
laboratory test to diagnose primary
hypothyroidism is measurement of serum
  • A. Free T4
  • B. Thyroglobulin
  • C. Thyroid antibodies
  • D. Total T3
  • E. TSH 

31
Among the following, the most sensitive
laboratory test to diagnose primary
hypothyroidism is measurement of serum
  • A. Free T4
  • B. Thyroglobulin
  • C. Thyroid antibodies
  • D. Total T3
  • E. TSH 

32
An 8-year-old girl has a 2 year decline in growth
velocity, as determined by plotting her height on
a standard growth curve. At age 6 years, her
height was at the 60th at age 7 years, it was
at the 40 at age 8 years, it was at the 10th
. Her parents are of average height. Her history
is otherwise unremarkable, and physical exam
reveals no abnormalities, although her thyroid
gland cannot be palpated. The pair of laboratory
tests that would best help explain the cause of
this patient's recent growth retardation is
  • A. Free T4 and T3
  • B. Growth hormone and blood urea nitrogen
  • C. Thyroid ultrasonography and technetium
    pertechnate scan
  • D. T4 and free T4
  • E. TSH and free T4

33
An 8-year-old girl has a 2 year decline in growth
velocity, as determined by plotting her height on
a standard growth curve. At age 6 years, her
height was at the 60th at age 7 years, it was
at the 40 at age 8 years, it was at the 10th
. Her parents are of average height. Her history
is otherwise unremarkable, and physical exam
reveals no abnormalities, although her thyroid
gland cannot be palpated. The pair of laboratory
tests that would best help explain the cause of
this patient's recent growth retardation is
  • A. Free T4 and T3
  • B. Growth hormone and blood urea nitrogen
  • C. Thyroid ultrasonography and technetium
    pertechnate scan
  • D. T4 and free T4
  • E. TSH and free T4

34
You receive notice that a male infant in your
practice had an elevated TSH level on newborn
screening. The most important laboratory test to
obtain immediately is a measure of
  • A. Free T4
  • B. Thyroglobulin
  • C. Thyroid antibody
  • D. Total T3
  • E. Thyroid stimulating hormone

35
You receive notice that a male infant in your
practice had an elevated TSH level on newborn
screening. The most important laboratory test to
obtain immediately is a measure of
  • A. Free T4
  • B. Thyroglobulin
  • C. Thyroid antibody
  • D. Total T3
  • E. Thyroid stimulating hormone

36
Although the prognosis for normal intellectual
and neurologic function and linear growth can be
excellent for children who have congenital
hypothyroidism, delaying treatment beyond which
of the following ages is likely to be associated
with impairments
  • A. 24 hours
  • B. 2 weeks
  • C. 3 months
  • D. 6 months
  • E. 1 year

37
Although the prognosis for normal intellectual
and neurologic function and linear growth can be
excellent for children who have congenital
hypothyroidism, delaying treatment beyond which
of the following ages is likely to be associated
with impairments
  • A. 24 hours
  • B. 2 weeks
  • C. 3 months
  • D. 6 months
  • E. 1 year

38
A 15-year old female presents with an
asymptomatic goiter. She has type I diabetes that
was diagnosed at age 7 years. Of the following,
the study that is most likely to be used to
establish the diagnosis is
  • A. Measurement of antiperoxidase antibodies
  • B. Needle biopsy of the thyroid
  • C. Technetium thyroid scan
  • D. Thyroid binding globulin level
  • E. Ultrasonography of the thyroid

39
A 15-year old female presents with an
asymptomatic goiter. She has type I diabetes that
was diagnosed at age 7 years. Of the following,
the study that is most likely to be used to
establish the diagnosis is
  • A. Measurement of antiperoxidase antibodies
  • B. Needle biopsy of the thyroid
  • C. Technetium thyroid scan
  • D. Thyroid binding globulin level
  • E. Ultrasonography of the thyroid

40
You are evaluating a 15-year-old girl who is
concerned about being overweight. Physical
examination reveals a weight of 90.9 kg (gt95)
and height of 170 cm (90). Findings on the
remainder of the examination, including the
thyroid gland, are normal. The total T4
concentration is 3.1 mcg/dL (normal is 5.6-11.7)
and the TSH level is 4.5 microIU/mL (normal
0.6-6.3). Repeat studies confirm these results,
and a 3,5,3-triiodothyronine (T3) resin uptake is
52 (normal 25-35). Of the following the most
likely diagnosis is
  • A. Hashimotos thyroiditis
  • B. Hyperthyroidism
  • C. Primary (thyroid) hypothyroidism
  • D. Secondary (central) hypothyroidism
  • E. Thyroid binding globulin deficiency

41
You are evaluating a 15-year-old girl who is
concerned about being overweight. Physical
examination reveals a weight of 90.9 kg (gt95)
and height of 170 cm (90). Findings on the
remainder of the examination, including the
thyroid gland, are normal. The total T4
concentration is 3.1 mcg/dL (normal is 5.6-11.7)
and the TSH level is 4.5 microIU/mL (normal
0.6-6.3). Repeat studies confirm these results,
and a 3,5,3-triiodothyronine (T3) resin uptake is
52 (normal 25-35). Of the following the most
likely diagnosis is
  • A. Hashimotos thyroiditis
  • B. Hyperthyroidism
  • C. Primary (thyroid) hypothyroidism
  • D. Secondary (central) hypothyroidism
  • E. Thyroid binding globulin deficiency

42
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