Hashimoto Thyroiditis

1
Hashimoto Thyroiditis

• Kathleen Dollins, MD, MT(ASCP)
• TTUHSC Department of Pediatrics
• Lubbock, Texas

2
Abstract

• Hashimoto thyroiditis may present itself in
  several ways. Many times children may present
  with a goiter or growth retardation, but
  otherwise may be asymptomatic. However, as the
  thyroiditis progresses over several years, the
  clinical presentation may change.
• This case demonstrates how a 7-year-old male who
  presented with a chief complaint of vomiting
  fecal matter revealed a wide manifestation of
  clinical symptoms of Hashimoto thyroiditis that
  remained undiagnosed and untreated for a period
  of approximately 3-4 years.

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Background/Objectives

• This case reveals the wide constellation of
  clinical manifestations that can occur with
  hypothyroidism and the progression of the
  symptoms when the disease remains untreated.
• This case demonstrates the importance of a
  thorough history and review of symptoms along
  with a complete physical exam.

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History of Present Illness

• Chief Complaint
• Vomiting fecal matter
• History of Present Illness
• 7 year-old-male who presented to the Emergency
  Center after 4-5 episodes of vomiting the
  previous night.
• The patients mother stated the vomitus looked
  and smelled like fecal matter, and it did not
  contain any blood.
• The patient has a history of constipation since
  birth with a stooling pattern of 1 bowel movement
  every three days (small, pellet-like stools).
• Last stool was 3 days ago
• The patient also complained of vague abdominal
  pain, nonspecific in nature.

5
Medical History

• Past Medical History
• Asthma (Last exacerbation at age 4)
• Possible Muscular Dystrophy and/or Autism (No
  final diagnosis given to parents)
• Birth History
• Full term, C-section secondary to fetal
  decelerations. Normal newborn stay. Birth
  weight 6lb, length 19in
• Past Surgical History
• None

6
Medical History Continued

• Immunizations UTD
• Current Meds None
• Allergies Histinex (hives)
• Family History
• Mother with Graves disease, Thyroidectomy,
  Irritable bowel syndrome
• Father with Bipolar Type II, Asthma, Gout,
  Arthritis
• Maternal Aunt with Hypothyroidism
• Maternal Grandmother with Hypothyroidism,
  Hepatitis C, Emphysema

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Medical History Continued

• Social History
• Patient moved to West Texas from East Texas one
  week prior to presentation, and has not adjusted
  well (according to mother). Patients parents
  had moved 1 month prior, while patient stayed
  with his paternal grandparents. Patient has one
  younger brother.
• Developmental History
• Patient is in the first grade and was held back
  from entering the 2nd grade. He is currently
  doing poorly in school.
• Patient is very withdrawn and has had poor social
  skills since age 4 with a possible diagnosis of
  Autism.
• Patients parents filed for bankruptcy 1 week ago
  due to overwhelming debt from patients previous
  diagnostic medical workup.

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Review of Systems

• General
• Fatigued since age 4
• No weight gain since age 4
• Negative for fevers
• HEENT
• Negative for any recent sore throat or congestion
• Negative for eye redness, tearing, or discharge
• Cardiovascular
• Negative for history of heart murmur or irregular
  heart beat

• Respiratory
• Positive for cough
• Negative for labored breathing or wheezing
• GI
• Positive for bad breath
• Positive for constipation, vomiting, and
  abdominal pain (see HPI)
• GU
• Negative for foul smelling urine, hematuria or
  dysuria

9
Review of Systems Continued

• Musculoskeletal
• Positive for bilateral leg pain since age 4
• Positive for muscle weakness since age 5
• Patient required assistance if he had to walk
  greater than 50 yards
• Patient would drag his legs
• Neurological
• Negative for seizures

• Skin/Hair/Nails
• Positive for chronic dry skin on arms and legs
• Positive for hair falling out
• Positive for very dry hair
• Psychiatric
• Positive for possible diagnosis of autism
• Endocrine
• Positive for no growth since age 4

10
Physical Examination

• General
• This is a very small, withdrawn 7 year old boy
  who makes little to no eye contact and appears as
  if he is 4 years old. There is an observed fecal
  odor in the room.
• Vitals
• Age 7yr 4mo
• Temp 99.7 F, Pulse 67, Respirations 20, BP 111/69
• Weight 17.3 kg (lt5), Height 39.5 in (ltlt5)

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Growth Chart
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Physical Examination Continued

• Skin
• Dry, scaly skin on the bilateral upper and lower
  extremities
• HEENT
• NC/AT, PERRLA, EOMI
• OP slightly dry mucous membranes with
  malodorous breath
• Nose no rhinorrhea noted
• Neck
• Supple, No lymphadenopathy
• No thyroid palpable

13
Physical Examination Continued

• Lungs
• Clear to auscultation bilaterally. No wheezes,
  rales, or rhonchi
• Heart
• Irregular rate and rhythm with bradycardia. No
  murmurs, gallops, or rubs heard
• Abdomen
• Soft, nontender, nondistended with no palpable
  bowel. No hepatospleenomegaly

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Physical Examination Continued

• Genitalia
• Tanner I male, testes descended bilaterally
• Rectal
• Good tone with stool noted in the vault
• Extremities
• Clubbing appearance of the fingernails
• Increased muscle mass in bilateral calf muscles

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Physical Examination Continued

• Neurological
• CN II-XII intact, Finger to nose intact,
  sensation intact, stereognosis intact, position
  sense intact
• Strength while in bed 5/5 throughout, however
  patient was unable to climb back into bed without
  assistance
• Reflexes hyper-reflexive with slow release
  (especially noted in patellar and Achilles)
• Gait Abnormal. Patient walked on his heels
• Balance Poor while balancing on his Left foot.
  Good balance on the Right foot

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Diagnostic Studies

• TSH gt200 mcIntUnit/mL (0.27-4.20)
• Free T4 lt0.02 ng/dL (0.93-1.70)
• Antithyroid Peroxidase Antibody 33,763 Intl
  Unit/mL (lt35)
• Antithyroglobulin Antibody gt150,000 Intl Unit/mL
  (lt20)
• Thyroglobulin 0.4 ng/mL (Adult range 2-3)
• Bone Age Between 2 years and 2 years 6months
• EKG Bradycardia, PACs, Right bundle branch
  block
• CK 512 Intl Unit/L (26-308)
• WBC 6.4, Hgb/Hct 9.5/27.1, Plt 253

19
Hospital Course

• The patient was admitted to the pediatric floor
  where he was given oral GoLYTELY and Milk of
  Molasses enemas.
• The patient stooled without any problems.
• Endocrinology was consulted.
• The patient was started on Synthroid 88mcg daily.
• The patient was discharged the following morning
  with prescriptions for Synthroid and Miralax.
• The patient followed up in the Endocrine clinic 6
  weeks later. His activity and energy levels had
  dramatically increased, and he was no longer
  requiring assistance to walk.

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Hashimoto Thyroiditis

• General
• Most common cause of thyroid disease in children.
• Most common cause of acquired hypothyroidism.
• Autoimmune in origin and associated with Graves
  disease.
• Etiology
• First described by Dr. Hashimoto in 1912 as a
  lymphocytic infiltration of the thyroid gland
  presenting as a goiter.
• HLA haplotypes are associated with goiter and
  thyroiditis (HLA-DR4, HLA-DR5) and with atrophic
  variant (HLA-DR3).
• Thyroid antiperoxidase antibodies and Thyrotropin
  receptor-blocking antibodies are commonly found.
• Antithyroglobulin antibodies occur, but are more
  common in adults.

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Hashimoto Thyroiditis

• Clinical Manifestations
• GirlsBoys 6-71
• More common after age 6 with a peak during
  adolescence.
• Most common manifestations are goiter and growth
  retardation.
• Most often, the thyroid is diffusely enlarged,
  firm, and nontender. However, it may present as
  a multinodular goiter or a single nodule.
• With time, the goiter may not change, may become
  smaller, or may disappear.
• May present with goiter alone, goiter and
  hypothyroidism, goiter and euthyroid
  (asymptomatic), or with transient hyperthyroidism
  followed by hypothyroidism.
• Patients with Hashimoto thyroiditis and
  subclinical hypothyroidism may progress to overt
  hypothyroidism.

22
Hashimoto Thyroiditis

• Clinical Manifestations Continued
• Autosomal dominant inheritance of autoantibodies
  with reduced penetrance in males
• 5-25 of siblings or parents of affected children
  may develop autoimmune hypothyroidism
• Associated with other autoimmune disorders
• Clinical features include myxedematous skin, dry
  hair and skin, cold intolerance, fatigue,
  bradycardia, constipation, anemia, growth
  retardation with decreased bone age, delayed
  tooth eruption, and possible slipped capital
  femoral epiphysis.

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Hashimoto Thyroiditis

• Laboratory
• Definitive diagnosis is by thyroid biopsy
  however this is rarely indicated
• Thyroid function tests are often normal
• TSH may be elevated
• Thyroid ultrasound shows scattered
  hypoechogenicity
• Thyroid peroxidase antibodies are common
• Antithyroglobulin test for thyroid antibodies is
  positive 50 of the time
• Radiograph of the left hand and wrist (bone age)
  may show growth retardation

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Hashimoto Thyroiditis

• Treatment
• Daily replacement of sodium-L-thyroxine
  (50-150mcg daily)
• Behavioral problems may start after beginning
  therapy because the child has more energy.
• The childs appearance may change dramatically,
  and the child may lose weight.
• Pubertal development and bone maturation should
  be monitored closely to evaluate for too rapid of
  progression.
• TSH should not be measured less than 6 weeks
  after therapy is started.

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Hashimoto Thyroiditis

• Prognosis
• Cognition If hypothyroidism is acquired after
  age 3, there is not a risk of irreversible
  long-term effects.
• Birth to age 3 is a critical period of brain
  development.
• In most patients with chronic autoimmune
  thyroiditis the hypothyroidism will be permanent.

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References

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• Brams E. Thyroid Disease A Case-Based and
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  Jersey Humana Press, 2005. Pages 71-77
• Braverman L, Utiger R. Werner Ingbars The
  Thyroid. Philadelphia Lippincott Williams
  Wilkins, 2005. Pages 1041-1047, 411-416, 701-714
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