Evaluation of the role of ultrasonography in diagnosis of autoimmune thyroiditis in goitrous children

OBJECTIVES: To evaluate the role of thyroid ultrasound in children with autoimmune thyroiditis diagnosed either on cytopathology or by the presence of thyroid peroxidase antibodies. DESIGN AND SETTINGS: Children presenting for the first time to the Thyroid Clinic at the Institute of Nuclear Medicine and Allied Sciences for the complaint of goiter over a two year period (January 2005-December 2006) were studied. SUBJECTS: 695 school children (244 boys and 451 girls) aged 5-18 year were studied. METHODS: Children were subjected to thyroid ultrasound, cytopathology, thyroid peroxidase antibody and thyroid function tests. RESULTS: Overall, 16% of goitrous children had hypoechogenicity on ultrasound, 15.2% had cytopathological evidence of thyroiditis, 10.6% had positive thyroid peroxidase antibodies and 25.2% had abnormal thyroid function tests. Subjects with hypoechogenicity had higher percentage of thyroiditis on cytopathology (41.4% vs. 10.3%; P<0.01), thyroid peroxidase antibody positivity (30.6% vs. 6.8%; P<0.01) and thyroid dysfunction (46.8% vs. 21.2%; P<0.01) than those with normal echogenicity. CONCLUSION: Thyroid USG has a useful, though limited, role in excluding thyroid disease in children. The sensitivity of echogenicity for the diagnosis of autoimmune thyroiditis in children is less than that reported in adults.     

A 5-year-old boy with atrophic autoimmune thyroiditis caused by thyroid-stimulation blocking antibodies

A 5-year-old boy was presented for a growth disturbance, which was initially noted at 3 years of age. Endocrinological testing identified severe hypothyroidism, defined by the following levels: TSH 990.5 microU/mL, F-T3 0.26 pg/mL, and F-T4 0.09 ng/dL. Serum anti-thyroid peroxidase (TPO) antibodies were 158 IU/mL and serum thyroid-stimulation blocking antibodies (TSBab) levels were 82.1 IU/mL (normal range < 45.6). Thyroid scintigraphy with 99mTc showed markedly decreased uptake, and magnetic resonance imaging (MRI) revealed pituitary hyperplasia. He was diagnosed with atrophic autoimmune thyroiditis. His thyroid function and pituitary size normalized following thyroid hormone replacement therapy. We report a rare case of a young boy with atrophic thyroiditis caused by TSBab.     

Acute suppurative thyroiditis in children

BACKGROUND: Acute suppurative thyroiditis in children is rare and is often related to a pyriform sinus fistula or thyroglossal duct remnant, especially when it is recurrent. METHODS: From January, 1985, through December, 2000, 15 children with acute suppurative thyroiditis were treated. Their clinical, laboratory and radiologic findings were reviewed and analyzed. RESULTS: There were 8 girls and 7 boys, with a mean age at diagnosis of 6.1+/-2.9 years (range, 1.5 to 9.8). A thyroid mass was present on the left in 13 and on the right in 2 (P < 0.05). Fever, neck pain and swelling were the most common symptoms and signs. Seven patients (46.7%) had recurrent disease. Needle aspiration for Gram stain and bacterial cultures were done, and pathogenic organisms were identified on culture in 8 patients but were found only on Gram stain in 2 patients. In one-half of the patients with positive cultures, mixed pathogens were found. The most common organisms isolated were streptococcal species (50%). Barium esophagography was performed in all patients, and 5 (33.3%) had a pyriform sinus fistula on the left. Only 1 of the recurrent patients had a fistula. Thyroid scans were performed in 13 patients, of whom 12 (92.3%) had decreased radioactive uptake. Thyroid function tests were normal in all 15. CONCLUSIONS: Acute suppurative thyroiditis is usually caused by oropharyngeal flora, resulting in mixed pathogens on culture. Broad spectrum antibiotics should be given once cultures have been obtained. Imaging studies might be helpful in the diagnosis of acute suppurative thyroiditis.     

Increased serum creatinine associated with severe primary hypothyroidism

A case of myxoedema due to Hashimoto's thyroiditis associated with a significant increase in serum creatinine is reported. Thyroid hormone replacement therapy resulted in normalization of the serum biochemistry within 1 month.     

Diagnostic role of thyroid elastography in pediatric patients with Hashimoto's thyroiditis and Graves’ disease: A prospective controlled study

ObjectiveHashimoto's thyroiditis and Graves’ disease are autoimmune diseases of the thyroid gland, and both diseases are diagnosed with ultrasound findings and autoantibody height. However, ultrasound (US) findings may be normal in both diseases rarely. In some pediatric studies, it was reported that shear wave velocity values in autoimmune thyroiditis were significantly higher than normal thyroid parenchyma and it was recommended to be used as a diagnostic method. Our study will address the evaluation of patients with Hashimoto's thyroiditis and Graves’ disease by thyroid elastography and the role of this method in diagnosis.Materials and methods28 patients with Hashimoto's thyroiditis, 20 patients with Graves’ disease and 40 healthy controls were enrolled in our study prospectively. Thyroid Elastography and US were applied to all patients.ResultsIn US, Hashimoto's thyroiditis had a hypoechoic echo pattern compared to graves’ disease (p < 0.05). When shear wave velocity (SWV) value of children with Hashimoto's thyroiditis and Graves’ disease were compared with the control group, thyroid tissue showed more stiffness in both disease groups (p = 0.001). When SWV values were compared between Hashimoto's thyroiditis and Graves’ disease, there was no statistically significant difference (p = 0.73).ConclucionSWV values were found to be higher in children with Hashimoto's thyroiditis and Graves’ disease compared to the control group and contributes to the diagnosis of these diseases. However, the elastography technique alone is not sufficient to differentiate. Hashimoto's thyroiditis and Graves’ disease.     

Transient neonatal hypothyroidism in a neonate born of a mother with Hashimoto's thyroiditis

Transient neonatal hypothyroidism was found in a boy whose mother was treated for hypothyroidism due to Hashimoto's thyroiditis. During the neonatal period the infant had antithyroid microsomal and antithyroglobulin antibodies and immunoglobulins inhibiting cyclic AMP production by thyroid cells in vitro. After one year of treatment, all antibodies disappeared. Thyroid scintiscan and fixation in the neonatal period was negative and became positive 2 months after stopping treatment with normal fixation and cervical thyroid picture. The mother's serum contained the same antibodies: they crossed the placental barrier and were responsible for neonatal pathological manifestations.     

Thyroid antibodies in children and adolescents with thyroid disorders

Thyroid antibodies were determined by three different techniques in the sera of 125 children and adolescents with thyroid disorders and in the sera of 53 short, normal children without thyroid dysfunction. The incidence of antithyroglobulin antibodies in patients with thyroiditis was highest when measured by radioimmunoassay (85%), less than when measured by hemagglutination (24%), and least by antimicrosomal antibodies (7%). No patient who had initially negative serum for RATA subsequently had positive tests during follow-up of five to 24 months, whereas eight of 31 patients with initially negative serum for ATA later developed positive tests. Treatment appeared to have a suppressive effect on RATA, but not on ATA titers, in hypothroid patients with clinical thyroiditis. The incidence of hypothyroidism in the patients with clinical thyroiditis on initial presentation was significant (37%) and suggests that identification of children and adolescents with thyroiditis is important to ensure adequate medical follow-up.     

Complications after preventive mumps vaccination in West Germany (including multiple preventive vaccinations)

Since the introduction of mumps vaccination in the Federal Republic of Germany 34 untoward vaccinal reactions were collected. In 2 cases of aseptic meningitis after mumps immunisation mumps virus was isolated from the CSF. The final investigation showed mumps virus (wild type) in one case; in the other a mumps vaccine-like strain (Jeryl-Lynn) was identified. Both patients recovered completely. These complications do not outweigh the enormous benefits of mumps immunisation.     

Pathologic and immune factors in thyroid disease.

Thyroid glands from 33 children with hyperthyroidism and nine with juvenile lymphocytic thyroiditis were examined histologically and for IgG, IgA, IgM, and C3 by immunofluorescent staining. There was no significant difference between glands with JLT and those with hyperthyroidism in the degree of lymphoid infiltration or lymphoid follicle formation. In thyroiditis there was no correlation between the degree of histologic abnormalities and the presence of immunofluorescent staining for IgG, IgM, or IgA. In hyperthyroidism there was a correlation between the degree of histologic abnormalities and the presence of IgG. In both groups of patients LI and LFF were distinctly more severe in glands positive for C3. Postsurgical hypothyroidism correlated with LI but not with LFF, IgG, or C3.     

Congenital mumps pneumonia: a rare cause of neonatal respiratory distress

A case of a fullterm infant with severe neonatal respiratory distress due to mumps infection is reported. Pregnancy was complicated by a self-limited febrile illness of the mother about two weeks before birth. Foetal heart rate patterns and delivery were normal. Immediately after birth the infant needed mechanical ventilation. Bacterial infections, as well as congenital cardiac or pulmonary malformations were excluded. The infant showed serologic evidence of mumps infection: IgM antibodies to mumps virus were highly positive. He expired on the 9th day of life due to bilateral pneumothoraces and pneumopericardium. Post-mortem examination showed interstitial pneumonia with intra-alveolar multinucleated giant cells, suggesting viral disease. This case demonstrates, that mumps pneumonia should be included in the differential diagnosis of severe neonatal respiratory distress in fullterm neonates.     

Ultrasound imaging in diffuse thyroid disorders of children

The diagnosis of diffuse thyroid disorders in children is based mainly on hormone and antibody determinations and a cytologic sample taken by aspiration biopsy. The cytologic sample is not always obtainable in small children or when the thyroid gland is not enlarged. Thyroid antibodies lead to diagnosis only in a proportion of cases. Gamma imaging is not recommended in children because of the radiation risk. The aim of this study was to demonstrate that ultrasound imaging can detect diffuse thyroid disorders in children. Ultrasound images were abnormal in 92% of all subjects; they were abnormal in 97% of cases with thyroiditis and in most cases ultrasound was diagnostic. With antibody determinations, only 60% of the cases of thyroiditis could be diagnosed. Ultrasound imaging--a risk-free method--should be included in the diagnostic investigation of thyroid disorders.     

Chronic autoimmune thyroiditis in the child]

OBJECTIVE: The aim of the study was to describe the clinical characteristics and long-term follow-up of a group of children with chronic autoimmune thyroiditis. PATIENTS AND METHODS: Sixty children (age: 11.9 +/- 2.7 years) were studied in a retrospective analysis. RESULTS: At diagnosis, 34 of the children were hypothyroid (compensated hypothyroidism, n = 15; true hypothyroidism, n = 19) and 26 euthyroid. Thyroid ultrasonography showed characteristic features of heterogenicity and/or hypoechogenicity in all patients. Other autoimmune diseases were found in ten subjects (17%) and 23% had a family history of thyroid disease. At the end of the follow-up, nine of 45 children (20% of the cases) followed up for at least one year (mean follow-up 4.4 +/- 3.7 years), demonstrated a change in thyroid function. Hypothyroidism was detected in two initially euthyroid patients. Among initially hypothyroid patients, seven (28%) recovered normal thyroid function, allowing L-thyroxine withdrawal for four weeks, after 1.5 to 8.4 years. No factor was found to be predictive of the course of the disease. All subjects treated with L-thyroxine for hypothyroidism reached normal final height. CONCLUSION: The natural course of chronic lymphocytic thyroiditis is variable and unpredictable. Recovery from hypothyroidism does occur and can be aided by the L-thyroxine withdrawal test. The disease requires lifelong thyroid surveillance, especially in women during pregnancy, in order to avoid a potential adverse effect on the future child.     

Autoimmune thyroid disease in Indian children with type 1 diabetes mellitus

The objective of the present study was to determine the prevalence of autoimmune thyroid disease in Indian children with type 1 diabetes mellitus by the assay of antibodies to thyroid peroxidase and thyroglobulin. The study population consisted of 35 children with type 1 diabetes mellitus and 32 healthy age- and sex-matched control children. Thyroid peroxidase antibodies (TPO) were determined by ELISA and thyroglobulin antibodies (TGA) by passive hemagglutination. Thyroid function tests and tests of glycemic control were also performed. These assays were repeated after six months and one year. TPO were observed in 19 (54.3%) patients compared to three (10%) controls, and TGA in 11 (31.4%) patients and none of the controls. Both these observations were statistically significant with p=0.0002 for TPO and 0.0016 for TGA. The prevalence of these antibodies was not different in boys and girls and did not change with the duration of diabetes. All patients who were positive for TGA were also positive for TPO. Thyroid function tests were abnormal in one patient who was found to have Hashimoto's thyroiditis. There is a definite need to screen all diabetic children for thyroid antibodies and carefully follow up those patients in whom these antibodies are positive.     

Congenital Mumps Pneumonia: a Rare Cause of Neonatal Respiratory Distress

ABSTRACT. A case of a full term infant with severe neonatal respiratory distress due to mumps infection is reported. Pregnancy was complicated by a self-limited febrile illness of the mother about two weeks before birth. Foetal heart rate patterns and delivery were normal. Immediately after birth the infant needed mechanical ventilation. Bacterial infections, as well as congenital cardiac or pulmonary malformations were excluded. The infant showed serologic evidence of mumps infection: IgM antibodies to mumps virus were highly positive. He expired on the 9th day of life due to bilateral pneumothoraces and pneumopericardium. Post-mortem examination showed interstitial pneumonia with intra-alveolar multinucleated giant cells, suggesting viral disease. This case demonstrates, that mumps pneumonia should be included in the differential diagnosis of severe neonatal respiratory distress in fullterm neonates.     

Ultrasound Imaging in Diffuse Thyroid Disorders of Children

ABSTRACT. The diagnosis of diffuse thyroid disorders in children is based mainly on hormone and antibody determinations and a cytologic sample taken by aspiration biopsy. The cytologic sample is not always obtainable in small children or when the thyroid gland is not enlarged. Thyroid antibodies lead to diagnosis only in a proportion of cases. Gamma imaging is not recommended in children because of the radiation risk. The aim of this study was to demonstrate that ultrasound imaging can detect diffuse thyroid disorders in children. Ultrasound images were abnormal in 92 % of all subjects; they were abnormal in 97 % of cases with thyroiditis and in most cases ultrasound was diagnostic. With antibody determinations, only 60 % of the cases of thyroiditis could be diagnosed. Ultrasound imaging–a risk-free method-should be included in the diagnostic investigation of thyroid disorders.     

Thyroid disease in the pediatric patient: emphasizing imaging with sonography

Thyroid disease does occur in the pediatric patient, and imaging plays an important role in its evaluation. A review is presented of normal development of the thyroid gland, the technique and indications for thyroid sonography, and key imaging features of congenital thyroid disorders (ectopic or absent thyroid, infantile goiter, thyroglossal duct remnants), benign thyroid masses (follicular adenoma, degenerative nodules, colloid and thyroid cysts), malignant masses (follicular, papillary and medullary carcinoma) and diffuse thyroid disease (acute bacterial thyroiditis, Hashimoto's thyroiditis, Grave's disease).     

Incidence of iodine deficiency in patients presenting with goitre--discrepancy between clinical and ultrasonographic evaluation of the thyroid: comparison of patients with and without autoimmune thyroiditis--clinical, hormonal and urinary iodine excretion studies

In endemic areas iodine deficiency, and in iodine sufficient regions autoimmune thyroiditis, is the first aetiological factor for goitre. The aims of this study were to determine the incidence of iodine deficiency and autoimmune thyroiditis in patients presenting with goitre, to compare clinical and ultrasonographic assessment of thyroid size and to investigate the relationship between iodine and autoimmune thyroiditis. Patients diagnosed with goitre clinically (n = 204) were evaluated by their anthropometric measurements, ultrasonographic examination of the thyroid gland, thyroid function and TRH stimulation tests, thyroid autoantibodies and morning urinary iodine measurements. Thyroid volumes were evaluated according to three different reference criteria. Incidences of iodine deficiency and autoimmune thyroiditis were 54% and 17%. The incidences of iodine deficiency and excess were not significantly different in the autoimmune group (n = 35) compared to the non-autoimmune group (n = 169). In the autoimmune group, urinary iodine concentration correlated positively with serum thyroid hormones (FT3 r = 0.42, TT3 r = 0.38, TT4 r = 0.34) and negatively with serum TSH levels (r = 0.45). There were discrepancies between clinical and ultrasonographic evaluation of goitre, and between different reference criteria. This study revealed that iodine deficiency is still the first aetiological factor for goitre in our region and failed to show a relationship between iodine intake and autoimmune thyroid disease.     

GADA positivity at onset of type 1 diabetes is a risk factor for the development of autoimmune thyroiditis

Kordonouri O, Charpentier N, Hartmann R. GADA positivity at onset of type 1 diabetes is a risk factor for the development of autoimmune thyroiditis. Aim: To evaluate whether the presence of diabetes‐specific autoantibodies may predict the development of autoimmune thyroiditis (AIT) in children with type 1 diabetes (T1D). Methods: Glutamic acid decarboxylase antibodies (GADA), tyrosine phosphatase IA2 antibodies (IA2A), and insulin autoantibodies (IAA) were determined at T1D onset in 341 children and adolescents. Thyroid antibodies (anti‐TG, anti‐TPO), thyroid stimulating hormone (TSH), T₃ and T₄ were measured in 335 patients at T1D onset and thereafter annually with a follow‐up time of 1–15 yr. In case of thyroid antibody positivity and/or TSH elevation, thyroid gland sonography was performed. Treatment with l ‐thyroxine was started if persistent elevation of TSH and/or thyroid volume was present. Results: The majority of patients (92.1%) had at least one T1D antibody (71.6% GADA, 73.0% IA2A, and 44.9% IAA). GADA positive patients were older than those without GADA (p < 0.001). Thyroid autoimmunity was found in 15 of 335 patients (4.5%) at T1D onset with female preponderance (p = 0.013). At the end of follow‐up, 70 patients (20.9%) had developed thyroid autoantibodies [cumulative incidence (CI) 0.36 ± 0.06 at 10 yr of T1D]. In 30 patients (9.0%), AIT was diagnosed up to 9.4 yr after T1D onset (CI 0.24 ± 0.06 at 10 yr). AIT incidence was not influenced by IAA or IA2A positivity. In multivariate analysis, GADA positive patients were estimated to have a 3.5‐fold increased risk of AIT (CI 0.31 ± 0.11 at 10 yr) compared to those without GADA (p = 0.024). Conclusion: Based on the present results, a special focus should be given to GADA positive patients concerning screening for AIT as they are at increased risk to develop autoimmune thyroiditis.     

Electrophysiological tests of the hearing organ in Hashimoto's disease

Thyroid gland diseases resulting from an autoimmunological process may influence the hearing organ. The aim of this study was to assess peripheral and central parts of the hearing organ in children with Hashimoto's thyroiditis. Thirty children (mean age 14.9 years) with Hashimoto's thyroiditis were examined. Patients were euthyroid, and presented high blood concentration of antithyroperoxidase (ATPO) antibodies. Pure tone audiometry, tympanometry, otoacoustic emissions (DPOAEs), and brain auditory evoked potentials (BAEPs) were performed. None of the patients had any complaints about hearing acuity; pure tone audiometry, tympanometry, and DPOAEs were normal in all patients. There were considerable disturbances in auditory nerve and brainstem neural conduction in BAEPs. There was positive correlation between the blood concentration of ATPOA and the extent of the disturbances in the central part of the hearing organ. One should consider the possible presence of subclinical Hashimoto's encephalopathy affecting the central part of the auditory organ.     

Epidemiologic studies on Mumps

An intrafamilial serological and virological surveillance of mumps was carried out in Nagoya, a Japanese large city; where urbanization has been in progress rapidly and children are suffering from mumps sporadically nearly all the year around. Fourty five families with sporadic cases of mumps were studied. Of 59 sensitive contacts in the family, 33 suffered from clinically apparent mumps and 24 progressed subclinical infection. Only two of them escaped from the infection after exposure. Subclinical infections were more frequent in younger children. Among 7 sensitive contacts who resulted in subclinical infection after the exposure, 5 children were found to discharge mumps virus. Virus was also isolated from two mothers of the indicator cases, although their serological examinations revealed that they were apparently re-infected persons. It may be possible to postulate that 1) in the families dwelling in the urban area of the city, mumps virus has very high communicability, 2) subclinical infections were more frequent in younger children, 3) subclinically infected and re-infected persons would be sources of virus transmission, as well as mumps patients.