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Hashimoto Thyroiditis Hashimoto Thyroiditis Paulina Paciej Group 5

hashimoto thyroiditis

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Page 1: hashimoto thyroiditis

Hashimoto ThyroiditisHashimoto Thyroiditis

Paulina PaciejGroup 5

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In 1912 Hashimoto described four patients with a chronic disorder of the thyroid, which he termed struma lymphomatosa. The thyroid glands of these patients were characterized by diffuse lymphocytic infiltration, fibrosis, parenchymal atrophy,

and an eosinophilic change in some of the acinar cells.

Clinical and pathologic studies of this disease have appeared frequently since Hashimoto's original description.

Dr. Hakaru Hashimoto

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The disease has been called Hashimoto's thyroiditis, chronic thyroiditis, lymphocytic thyroiditis, lymphadenoid goiter, and recently autoimmune thyroiditis. Classically, the disease occurs as a painless, diffuse enlargement of the thyroid gland in a young or middle-aged woman. It is often associated with hypothyroidism. The disease was thought to be uncommon for many years, and the diagnosis was usually made by the surgeon at the time of operation or by the pathologist after thyroidectomy. The increasing use of the needle biopsy and serologic tests for antibodies have led to much more frequent recognition, and there is reason to believe that it may be increasing in frequency. It is now one of the most common thyroid disorders.

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Hashimoto ThyroiditisHashimoto 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◦ 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 ThyroiditisHashimoto Thyroiditis Clinical Manifestations

◦ Girls:Boys 6-7:1◦ 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.

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Hashimoto ThyroiditisHashimoto ThyroiditisClinical 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 ThyroiditisHashimoto ThyroiditisLaboratory

◦ 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 ThyroiditisHashimoto ThyroiditisTreatment

◦ Daily replacement of sodium-L-thyroxine (50-150mcg daily)

◦ Behavioral problems may start after beginning therapy because the child has more energy.

◦ The child’s 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 ThyroiditisHashimoto ThyroiditisPrognosis

◦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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Case 1Case 1

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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History of Present IllnessHistory 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 patient’s 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.

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FamilyFamily History HistoryFamily 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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Review of SystemsReview 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

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Review of Systems Review of Systems ContinuedContinued 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

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Physical ExaminationPhysical ExaminationGeneral

◦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 (37,5C), Pulse 67, Respirations

20, BP 111/69◦Weight 17.3 kg (<5%), Height 39.5 in

(<<5%)

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Hospital CourseHospital CourseThe 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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Case 2Case 2

Identical male twins with Hashimoto's thyroiditis were photographed at age 12. At age 8, they had the same height and appearance. During the intervening 4 years, small goiters developed and the growth of the twin on the right almost stopped. Biopsy indicated Hashimoto's thyroiditis in each twin's thyroid.

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ReferencesReferences Behrman R, Kliegman R, Jenson H. Nelson Textbook of

Pediatrics 17th Edition. Philadelphia: Elsevier Science, 2004. Pages 1878-1881

Bettendorf M. Thyroid disorders in children from birth to adolescence. Eur J Nucl Med Mol Imaging 2002; 29 Suppl 2:S439-46

Brams E. Thyroid Disease: A Case-Based and Practical Guide for Primary Care. Totowa, New Jersey: Humana Press, 2005. Pages 71-77

Braverman L, Utiger R. Werner & Ingbar’s: The Thyroid. Philadelphia: Lippincott Williams & Wilkins, 2005. Pages 1041-1047, 411-416, 701-714

Peter F. Thyroid dysfunction in the offspring of mothers with autoimmune thyroid diseases. Acta Paediatr 2005; 94(8):1008-10

Weetman AP. Autoimmune thyroid disease: propagation and progression. Eur J Endocrinol 2003; 148(1):1-9

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