Çocuk ve adölesan tirotoksikosiz vakalarının değerlendirilmesi-tek merkez deneyimi

Anahtar Kelimeler:

tirotoksikozis, Graves hastalığı

Outcomes of thyrotoxicosis in childhood and adolescence-single center experience

Giriş: Çocukluk ve adölesan çağındaki tirotoksikozis vakalarının klinik ve biyokimyasal özelliklerini, tedavi sonuçlarını değerlendirmek. Gereç ve yöntem: 2015-2019 yılları arasında pediatrik endokrin kliniğinde tirotoksikozis tanısıyla izlenen hastaların dosyaları geriye dönük incelendi. Bulgular: Çalışmaya dahil edilen 18 hastanın 14’ü (%77,7) kız, 4’ü (%22,2) erkekti. Tanı anındaki ortalama yaş 14,58±2,1 yıldı. Onbeş (%83,3) hasta Graves hastalığı, 3 (%16,6) hasta ise hashitoksikoz tanısı aldı. Graves hastalığı tanısı alan hastaların en sık başvuru şikayetleri halsizlik, taşikardi/çarpıntı, boyunda şişlikti. Diğer şikayetler, kilo kaybı, tremor ve gözde büyümeydi. Oniki (%66,6) hastada hipertiroidi açısından aile öyküsü pozitifti. Dokuz (%50) hastanın fizik muayenesinde guatr saptandı. Graves hastalığı tanısı alan 15 hastanın 5 (%33)’inde oftalmopati vardı. Metimazol başlangıç dozu 0,43±0,3 (0,1–1) mg/kg/gün ve ortalama izlem süresi 22,3±6,3 aydı. Hashitoksikoz tanısı alan 3 hastanın 2’sinin semptomları sadece beta-bloker tedavisiyle kontrol altına alınırken bir hastanın hiçbir medikal tedaviye ihtiyacı olmadı. 15 Graves hastasının 11 (%73)’ine tedavi başında beta bloker başlandı. Ortalama beta bloker dozu 31,6±10,2 (20-80) mg/gün saptandı. Metimazol başlanan hiçbir hastanın izleminde yan etki görülmedi. Sonuç: Graves hastalığı ve hashitoksikoz çocukluk ve adölesan dönemde görülen tritoksikoz vakaların çoğunu oluşturur. Hashitoksikozun prognozu daha iyi olduğu için bu iki hastalığı başlangıçta ayırt etmek gereklidir. Her ne kadar çocukluk ve adölesan çağı tirotoksikoz tedavisi için kanıta dayalı stratejiler olmasa da metimazol tedavide ilk seçenektir. Çocukluk ve adölesan çağı tirotoksikozu anlayabilmek için daha çok merkezin deneyimlerini paylaşmasına ihtiyaç vardır. Abstract Purpose: To evaluate the clinical and biochemical features and treatment outcomes of chilhood and adolescence thyrotoxicosis. Materials and methods: Medical records of the patients who had been diagnosed with thyrotoxicosis between 2015 and 2019 in the pediatric endocrinology clinic were screened retrospectively. Results: Of the 18 patients, 14 (77.7%) was females, 4 was (22.2% ) males. The median age at diagnosis was 14.58±2.1 years. Fifteen (83.3%) patients had been diagnosed with Graves’ disease and 3 (16.6%) patients had hashitoxicosis. The most common presenting complaints among patients with GD were malaise, tachycardia/palpitation and swelling in the neck. The other complaints were weight loss, tremor, enlargement of eyes. Twelve (66.6%) patients have family history. Goiter was detected in the physical examination of 9 (50%) patients. Of the 15 patients who diagnosed with GD, 5 (33%) patients had ophthalmopathy. The mean initial dose of methimazole was 0.4±0.3 (range 0.1–1) mg/kg/day and median follow-up duration was 22.3±6.3 months. Two of 3 patients diagnosed with hashitoxicosis were managed only with beta blocker and one patient did not need any treatment. Eleven (73%) of 15 GD patients received beta blocker initially. The mean initial dose of beta blocker was 31.6±10.2 (range 20-80) mg/day. Side effects were not seen any of 15 patients treated with methimazole. Conclusion: Graves’ disease and hashitoxicosis are the most common form of thyrotoxicosis in both children and adults. These two diseases should be distinguised at diagnosis since the prognosis is better in hashitoxicosis However, there is no evidence–based strategy for the management of childhood thyrotoxicosis, methimazol is the first treatment option in Graves’ disease. More experience of treatment responses are essential to understand thyrotoxicosis in children and adolescents.

Keywords:

thyrotoxicosis, Graves’ disease, hashitoxicosis childhood, adolescence,

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1. Franklyn JA, Boelaert K. Thyrotoxicosis. Lancet 2012;379:1155–1166. https://doi.org/10.1016/S0140-6736(11)60782-4
2. Léger J, Oliver I, Rodrigue D, Lambert AS, Coutant R. Graves’ disease in children. Ann Endocrinol 2018;79:647–655. https://doi.org/10.1016/j.ando.2018.08.001
3. Rodanaki M, Lodefalk M, Forssell K, Arvidsson CG, Forssberg M, Åman J. The incidence of childhood thyrotoxicosis is increasing inboth girls and boys in Sweden. Horm Res Paediatr 2019;91:195-202. https://doi.org/10.1159/000500265
4. Havgaard Kjaer R, Smedegard Andersen M, Hansen D. Increasing Incidence of Juvenile Thyrotoxicosis in Denmark: A Nationwide Study, 1998-2012. Horm Res Paediatr 2015;84:102-107. https://doi.org/10.1159/000430985
5. Léger J, Carel JC. Diagnosis and management of hyperthyroidism from prenatal life to adolescence. Best Pract Res Clin Endocrinol Metab 2018;32:373–386. https://doi.org/10.1016/j.beem.2018.03.014
6. Okawa ER, Grant FD, Smith JR. Pediatric Graves’ disease: decisions regarding therapy. Curr Opin Pediatr 2015;27:442-447. https://doi.org/10.1097/MOP.0000000000000241
7. Leger J, Carel JC. Management of endocrine disease: arguments for the prolonged use of antithyroid drugs in children with Graves’ disease. Eur J Endocrinol 2017;177:59-67. https://doi.org/10.1530/EJE-16-0938
8. Davies TF, Laurberg P, Bahn RS. Hyperthyroid disorders. In: Melmed W, ed. Textbook of endocrinology. 13th ed. Philadelphia: Elsevier; 2016;369-415.
9. Neyzi O, Bundak R, Gökçay G, Günöz H, Furman A, Darendeliler F, Baş F. Reference values for weight, height, head circumference, and body mass index in Turkish children. J Clin Res Pediatr Endocrinol 2015;7:280-293. https://doi.org/10.4274/jcrpe.2183
10. Ross DS, Burch HB, Cooper DS, et al. 2016 American thyroid association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid 2016;26:1343–421. https://doi.org/10.1089/thy.2016.0229
11. Effraimidis G, Wiersinga WM. Mechanisms in endocrinology: autoimmune thyroid disease: old and new players. Eur J Endocrinol 2014;170:241–252. https://doi.org/10.1530/EJE-14-0047
12. Szczapa-Jagustyn J, Gotz-Więckowska A, Kocięcki J. An update on thyroid-associated ophthalmopathy in children and adolescents. J Pediatr Endocrinol Metab 2016;29:1115-1122. https://doi.org/10.1515/jpem-2016-0122
13. Rivkees SA. 63 years and 715 days to the “boxed warning”: unmasking of the propylthiouracil problem. Int J Pediatr Endocrinol 2010;2010:658267. https://doi.org/ 10.1155/2010/658267
14. Weetman AP. Graves’ hyperthyroidism: how long should antithyroid drug therapy be continued to achieve remission? Nat Clin Pract Endocrinol Metab 2006;2:2–3. https://doi.org/10.1038/ncpendmet0068
15. Day Andrew J, Yeh Michael W, Livhits Masha J. Surgery for hyperthyroidism lowers cardiovascular mortality compared with radioactive iodine. Clinical Thyroidology 2018;30:15-17.
16. Bayramoğlu E, Elmaogulları S, Sagsak E, Aycan Z. Evaluation of long-term follow-up and methimazole therapy outcomes of pediatric Graves' disease: a single-center experience. J Pediatr Endocrinol Metab 2019;32:341-346. https://doi.org/10.1515/jpem-2018-0495
17. Léger J, Carel JC. Hyperthyroidism in childhood: causes, when and how to treat. J Clin Res Pediatr Endocrinol 2013;5:50–56. https://doi.org/10.4274/jcrpe.854
18. Thomusch O, Sekulla C, Billmann F, Seifert G, Dralle H, Lorenz K. Risk profile analysis and complications after surgery for autoimmune thyroid disease. Br J Surg 2018;105:677-685. https://doi.org/10.1002/bjs.10770
19. Sung T-Y, Lee Y-mi, Yoon JH, et al. Long-term effect of surgery in Graves′ disease: 20 years experience in a single institution. Int J Endocrinol 2015;2015:1–6. https://doi.org/10.1155/2015/542641