how thyroid hyperfunction affects children and elderly , when to suspect and how to treat Summary of clinical manifestations and how to peck and diagnose and methods of treatment

2. HAMED RASHAD
Professor of Surgery Banha Faculty of Medicine

3. Thyrotoxicosis should be treated first
in any situation.
It has priority over every thing at any age
except emergencies In which even
it should be at least controlled first
with I.V beta blocker
Introduction

4. THYROTOXICOSIS
IN NEONATES

5. Neonatal Graves disease
 Neonatal Graves disease is rare even among
mothers with known hyperthyroidism
 Neonatal Graves disease is caused by the
transplacental passage of TSI (Thyroid
Stimulating Immunoglobulin)
 Only 1 in 70 infants of thyrotoxic mothers has
clinical symptoms

6. Neonatal Graves disease
 If the mother is taking antithyroid drugs, infants
are usually born asymptomatic
 Signs include tachycardia, wide pulse pressure,
irritability, tremor, and hyperphagia with poor
weight gain
 The baby may have exophthalmos and goiter

7. Neonatal Graves disease
 Neonates have a much higher risk of morbidity
and mortality from cardiac disease
 In severe cases, CHF can be observed
 Goiter can occasionally be large enough to cause
airway compression
 Long-term effects can include craniosynostosis
and developmental delay

8. THYROTOXICOSIS
IN CHILDREN

9. Hyperthyroidism is a relatively
rare condition in children
Graves disease accounts for more
than 95% of childhood cases of
hyperthyroidism

10. Causes
Transient
• Neonatal thyrotoxicosis
• Infectious : Acute & Subacute thyroiditis
• Drug – induced: Amiodarone, interferon
&interleukin
 Hashitoxicosis
• Iatrogenic: over dose of L-Thyroxin

11. Permanent causes
 Graves disease
 Toxic adenoma/ carcinoma
 Toxic nodular goiter
 McCune-Albright syndrome
Pituitary causes of thyrotoxicosis
 Pituitary adenoma
 Pituitary resistance to T4

12. Other causes:
 Exogenous thyroid hormone
 Iodine-induced hyperthyroidism (i.e., Jod-
Basedow phenomenon)
 Human chorionic gonadotropin (hCG)–
secreting tumors

13. Symptoms and signs
Unusual before age 5.
 Female 5 times  than male.
 Symptoms are like adults but Behavioral
symptoms predominate (Hyperkinetic child).
Thyrotoxic children are taller for their age.
Permanent brain damage and craniostenosis are
reported.

15. Exophthalmos

16. Diagnosis
 Suppressed TSH
 Elevated T4, Free T4, T3 levels
 Positive Thyroid Stimulating Antibodies:
– Thyroid Peroxidase
– Thyroglobulin
– Thyroid Stimulating Immunoglobulin

17. Isotope scan is very important

18. Graves Disease
I 123 or TC 99m Normal v/s Graves

19. Toxic Multinodular Goiter (TMG)

20. Toxic Single Adenoma (TSA)
Nucleotide
Scintigraphy

21. Treatment
 Three modalities for more than last 50
years
 Radioactive iodine, anti-thyroid drugs &
surgery
 None is optimal
 None interrupts the autoimmune process

22. Treatment choices
Clinical considerations
 Age of the patient
 Goiter size
 Urgency of treatment
 RAIU by the thyroid
 Physician preference
 Patient choice

23. Therapy:
??? I131
Choice is between antithyroid drugs and subtotal
thyroidectomy.
Antithyroid drugs
 Preferable initial therapy
 A permanent remission is expected in
50%.
 Two year treatment is recommended 
recurrence  another one year course.

24. Results of med treat :
 Decrease in size of goiter = remission
 Progressive enlargement of goiter =
hypothyriodism 
reduction of dose
or
thyroxine replacement

25. Antithyroid Drugs
High risk factors of relapse in children
 Large goiter
 History of previous relapse
 High TRAB titer
 Ophthalmopathy
 T3 predominant grave’s disease
 Low doses or short duration (31% remission rate
for 6 m. treatment and 82% for 2 years)

26. Antithyroid Drugs
Thionamide group
 Methimazole – Neomecazol - Cabemazol
Fewer doses / day (once daily), no bad taste and
no compliance problems
 Propylthiouracil - Thyrocil
More doses /day, bad taste, and no compliance
problems

27. Surgical treatment
Subtotal thyroidectomy was the most common
procedure Now Total Thyroidectomy
Indications
 Large goiter
 Severe thyrotoxicosis
 Failure of medical therapy
 Reaction or neutropenia to med. therapy.
 No permanent remission till age 15
 Exophthalmos not responding to treatment

28. I131Radioactive iodine
 There is no evidence to suggest that such
therapy has any adverse effects
 No effect on fertility
 No increased incidence of congenital
malformations
 No increase risk of cancer in-patients treated
with radioactive iodine or in their offspring
 But nobody can dare

29. Radioiodine
Necessary if
-Surgery is contraindicated
- Prior to surgery
Potential risk after the age 15
is low

31. Thyrotoxicosis in Elderly
Prevalence of TD increase with age
Hyperthyroidism above 60 ranges from
0.5 to 2.3%. twice that in younger populations
Fewer signs.
Anorexia and atrial fibrillation are commoner.
Tachycardia, fatigue and weight loss in more than
half.

32. Hyperthyroidism in the elderly
 Causes differ:
y young<50 old>70y
 M. Graves 92 % 33%
 Multinod.Goiter 4% 23 %
 Solit.Tox.Nod 4% 7%
 Iodine.ind.Thyrotox. 0% 37%

33. Symptoms differ
 Tachycardia, fatigue and weight loss are the
most frequent presenting symptoms in the
elderly.
 In more than 50 % one of these symptoms
 Triad in 32 %
 Next 5 most frequent symptoms in elderly:
Tremor, Dyspnea, Apathy, Anorexia,
Nervousness

34. In summary
 Presentation of hyperthyroidism in the
elderly:
 Less symptoms
 Nonspecific symptoms
 Less typical (adrenergic) symptoms

35. Symptoms differ
 Classical symptoms are less frequent :
Old Young
 Hyperactive reflexes 28 vs 96%
 Increased sweating 24 vs 95%
 Heat intolerance 15 vs 92%
 Tremor 44 vs 84%
 Nervousness 31 vs 84%
 Polydipsia 21 vs 67%
 Increased appetite 0 vs 57%

36. Symptoms/signs more
frequent in the elderly
 Atrial fibrillation: 32 vs 2 %
 Anorexia: 32 vs 4 %

37. Apathetic hyperthyroidism
First described by Lahey 1931
Occurs in 10-15 % of elderly with thyrotoxicosis
Features Weakness
Lethargy
Depression
Absent hyperkinesis
Apathetic appearance of the face
Lack of ocular signs
Lack of palpitation
Age related attenuation of the adrenergic tone and tissue
resistance to effect of thyroid hormone.

38. TREATMENT OPTIONS
Does not differ from those in young with some
precautions :
1- A lag of 1-2 months in improvement with I131
therapy = Betablockers to control.
2- Patients with coronary artery disease should
be controlled with antithyroid drugs to
achieve normal T4 levels before undergoing
radio ablation.
3- Medication should be given with the lowest
effective dose.

39. TREATMENT OPTIONS
4- Recurrence after control by medical
treatment in Grave’s is much lower.
5- Low risk patients with a large nodular
goiter  surgery is considered a good
choice.
6- In flail patients radio iodine treatment is
preferred.

41. Thyroid disease in pregnancy
 Thyroid disease is present in 2-5% of women.
 2nd more common endocrinal problem in pregnancy.
 Overt hypothyroidism occurs in 0.3-0.5%.
 Sub-clinical hypothyroidism in 2-3%.
 Hyperthyroidism in 0.1-0.4%.

42.  Autoimmune thyroid dysfunctions remain a common cause
of both hypo and hyperthyroidism.
 Grave’s disease accounts for more than 80% of all cases
of hyperthyroidism.
 Hashimoto thyroiditis the most common cause of
hypothyroidism.
 Postpartum thyroiditis affects 4-10% of women again is
an autoimmune disease.

43. THYROTOXICOSIS IN PREGNANCY
(1-2 per 1000 pregnancies)
Planning pregnancy for women with
thyrotoxicosis:
 Never use I131for scanning or treatment
 Control thyrotoxicosis before proceeding to
pregnancy (takes 3 - 6 months).
 Accidental use of I131 (Diagnostic) during
pregnancy is of no major harm.

44. Thyroid Functions in Pregnancy
 Thyroid functions are normal
 Although normal pregnant women may have
 Rapid heart rate.
 Sweating.
 Hot intolerance.
 Total T3 & T4 levels are increased
 high level of estrogen increases TBG

45.  It has been observed that patients with known history
of Graves disease tend to undergo remission during
pregnancy and exacerbation during the post partum
period.
 !! The overall down regulation of the maternal immune
system during pregnancy.

46. Diagnosis of hyperthyroidism in pregnancy:
 Symptoms:
May simulate euthyroid pregnant women ( tachycardia….
 Sings:
- Weight loss  obscured by weight gain in pregnancy.
- Eye signs.
- Thyroid swelling.
- Resting pulse above 100 / m. (That fail to slow during Valsalva)
- The presence of ONYCHOLYSIS (Separation of the distal nail from the nail bed).

47. Lab Tests
 The markedly elevated TBG during pregnancy
makes the standard free T4 not accurate
estimation of the true free T4.
 Newer non equilibrium dialysis method of free
T4 may be helpful.
 If in doubt repeat after 3-4 weeks.

48. Morbidity and mortality of
gestational thyrotoxicosis
 Fetal
- ↑ Neonatal mortality
- ↑ Low birth weight infants .
 Maternal
- ↑ risk of premature labour
- ↑ frequency of pre-eclampsia.
- ↑ CHF.

49. Treatment of hyperthyroidism during
pregnancy
There is no evidence that pregnancy makes
hyperthyroidism more difficult to cure.
 Therapy:
- Anti thyroid drugs or surgery.
- I131 is contra indicated.

50. 1. Propyl thiouracil (PTU):
- Drug of choice
- 100-150 mg / 8 hrs.
- Maximum 600 daily.
- Tapered to 100 mg daily.
- Does not cross placenta.
Methimazol (carbimazol):
- Still safe
- 5-15 mg/ 8hr.
- Tapered to 10 mg daily.
NB:
Disease becomes milder or remit totally Near term  drugs tapered or
discontinued.

51. 2. Blocking agents:
Are not recommended for long term
treatment during pregnancy.
 Adverse outcomes:
 Small placenta.
 Intrauterine growth retardation.
 Neonatal resp. distress.
 Impaired response to anoxic stress.
 Postnatal:
o Bradycardia.
o hypothermia.
o hypoglycemia.

52. 3-Surgery
- For patients with:
 Antithyroid drug reaction
 Poor compliance
 Drug dosage needed above the safe level. • Persistently
high dosages (PTU > 600 mg/d, Cab > 40 mg/d) are
required to control maternal disease
 Compressive symptoms

53. 3-Surgery
 Prepared with a β-adrenergic blocking agent and
a 10- to 14- day course of potassium iodide
Total thyroidectomy
•Better done after first trimester (↓↓ risk of abortion)
•Observe for post operative (hypothyroidism)
•Immediate replacement with 0.05 T4.

54. ‫لكم‬ ‫شكرا‬