Download The Many Faces of Hypothyroidism

Rob Lindsay, MD
Adjunct Professor of Pediatrics
University of Utah School of Medicine
10 year old girl with documented autoimmune (Hashimoto) thyroiditis
and hypothyroidism. Her initial TSH was > 1000mU/L.
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Type 1 Diabetes Mellitus
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Down Syndrome
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Turner’s Syndrome
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Celiac Disease
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Klinefelter’s Syndrome
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Serum Free T4 and TSH are sufficient
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Serum T3 levels often misleading
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If measuring total T4 also do T3 resin uptake or
thyroid binding protein
Antithyroglobulin and antithyroid peroxidase
antibodies
Thyroid imaging rarely indicated
NHANES III (1988 – 1994)
Adolescents 12-19 years of age
 6.3% positive antithyroglobulin
 4.8% positive antithyroid peroxidase
antibodies
 2:1 Female:Male
105 children with positive antibodies and
normal TSH followed for 5 years:
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65% remained euthyroid
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10% developed mild TSH elevation
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26% developed TSH twofold above normal
55 children with positive antibodies and mildly
elevated TSH levels:
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29% reverted to normal TSH
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29% were unchanged
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42% developed TSH twofold above normal
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1:3000 to 1:4000 in newborn infants
More common in Hispanic and Native
American infants at 1:2000
Less common in African American infants at
1:32,000
Consistently 2:1 Female:Male
 85%
are sporadic – 15% hereditary
 90%
permanent – 10% transient
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Only 5% suspected by clinical diagnosis
◦ At time of newborn screen
◦ At 2-3 weeks of age
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Birth weight and length normal
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OFC slightly increased
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Gestational age > 42 weeks in 33%
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Primary T4 measurement with backup TSH
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Primary TSH measurement
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Recall rate (T4 <10%, TSH > 20 mU/L
◦ Primary T4 - 0.3%
◦ Primary TSH – 0.05%
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Free T4 – Upper half of normal range:
◦ 1.4 – 2.3 ng/dl
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TSH < 10 mU/L
◦ May take one month of treatment
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Before Newborn Screening:
◦ If diagnosed between birth and 3 months
 IQ = 89
◦ If diagnosed between 3 and 6 months
 IQ = 71
◦ If diagnosed after 6 months
 IQ = 54
1 year-old child with undiagnosed/untreated congenital hypothyroidism who was born before
national screening programs for this condition. She was treated with replacement thyroid
hormone, and 6 months later had a more normal facial appearance but significant developmental
delays due to delay in diagnosis and treatment.
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New England Congenital Hypothyroidism
Collaborative
◦ Verbal IQ
◦ Performance IQ
◦ Full Scale IQ
At 6 years of age.
109
107
109
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New England Congenital Hypothyrodism Collaborative
◦ Inadequate treatment in first 3
years
IQ = 87
A small proportion may have:
 Language deficits
 Problems with visual-spatial integration
 Ataxia
 Gross and fine motor incoordination
 Muscle tone abnormalities
 Short attention span
 Strabismus
 10% will have sensorineural deafness
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