Ann Pediatr Endocrinol Metab.  2016 Sep;21(3):164-168. 10.6065/apem.2016.21.3.164.

Diagnostic difficulties by the unusual presentations in children and adolescents with Hashimoto thyroiditis

• Ersoy B
• Seniha KY
• Kızılay
• Yılmaz M
• CoÅŸkun S

• KMID: 2366793
• DOI: http://doi.org/10.6065/apem.2016.21.3.164

Abstract

Complex clinical presentation with diverse timing of particular symptoms may cause diagnostic difficulties, especially in children and adolescents. This paper presents diagnostic difficulties and pitfalls in 3 children with acquired primary hypothyroidism due to Hashimoto's thyroiditis (HT) presenting with unusual manifestations. We described 3 children with acquired primary hypothyroidism due to HT. One of our patients had musculoskeletal pain and was diagnosed and treated as having connective tissue disease. Another patient presented with chest pain, dyspnea, and swelling in the abdomen. She had a massive pericardial effusion (PE). Two patients had severe growth failure. A third patient with Down syndrome had a small PE. Her complaint was dyspnea during sleep. All patients improved with thyroxin therapy. Patients with hypothyroidism due to HT who have complicated clinical manifestations were misdiagnosed and mismanaged at childhood and adolescence. Growth failure is an important sign in children and adolescents. In the presence of complicated manifestations in children and adolescents, thyroid dysfunction must be considered in differential diagnosis.

Keyword

Hypothyroidism; Children; Musculoskeletal pain; Pericardial effusion; Hashimoto thyroiditis

MeSH Terms

Abdomen
Adolescent*
Chest Pain
Child*
Connective Tissue Diseases
Diagnosis, Differential
Down Syndrome
Dyspnea
Hashimoto Disease*
Humans
Hypothyroidism
Musculoskeletal Pain
Pericardial Effusion
Thyroid Gland
Thyroiditis
Thyroxine
Thyroxine

Figure

• 

  Fig. 1 Growth chart of case 1.

• 

  Fig. 2 X-ray examination of case 2 at presentation.

• 

  Fig. 3 Pericardial effusion exceeding 1 cm on echocardiography in case 3.

Reference

1. Radetti G. Clinical aspects of Hashimoto's thyroiditis. Endocr Dev. 2014; 26:158–170. PMID: 25231451.

2. Lee HS, Hwang JS. The natural course of Hashimoto's thyroiditis in children and adolescents. J Pediatr Endocrinol Metab. 2014; 27:807–812. PMID: 24756046.

3. Caturegli P, De Remigis A, Rose NR. Hashimoto thyroiditis: clinical and diagnostic criteria. Autoimmun Rev. 2014; 13:391–397. PMID: 24434360.

4. Martinez-Soto T, Deal C, Stephure D, Trussell R, Boutin C, Djemli A, et al. Pericardial effusion in severe hypothyroidism in children. J Pediatr Endocrinol Metab. 2010; 23:1165–1168. PMID: 21284330.

5. Duyff RF, Van den Bosch J, Laman DM, van Loon BJ, Linssen WH. Neuromuscular findings in thyroid dysfunction: a prospective clinical and electrodiagnostic study. J Neurol Neurosurg Psychiatry. 2000; 68:750–755. PMID: 10811699.

6. Anwar S, Gibofsky A. Musculoskeletal manifestations of thyroid disease. Rheum Dis Clin North Am. 2010; 36:637–646. PMID: 21092843.

7. Cakir M, Samanci N, Balci N, Balci MK. Musculoskeletal manifestations in patients with thyroid disease. Clin Endocrinol (Oxf). 2003; 59:162–167. PMID: 12864792.

8. Punzi L, Betterle C. Chronic autoimmune thyroiditis and rheumatic manifestations. Joint Bone Spine. 2004; 71:275–283. PMID: 15288851.

9. Finsterer J, Stöllberger C, Grossegger C, Kroiss A. Hypothyroid myopathy with unusually high serum creatine kinase values. Horm Res. 1999; 52:205–208. PMID: 10725787.

10. Madariaga MG. Polymyositis-like syndrome in hypothyroidism: review of cases reported over the past twenty-five years. Thyroid. 2002; 12:331–336. PMID: 12034059.

11. Sbrocchi AM, Chédeville G, Scuccimarri R, Duffy CM, Krishnamoorthy P. Pediatric hypothyroidism presenting with a polymyositis-like syndrome and increased creatinine: report of three cases. J Pediatr Endocrinol Metab. 2008; 21:89–92. PMID: 18404977.

12. Villar J, Finol HJ, Torres SH, Roschman-González A. Myopathy in patients with Hashimoto's disease. Invest Clin. 2015; 56:33–46. PMID: 25920184.

13. Werder EA, Torresani T, Navratil F, Arbenz U, Eiholzer U, Pelet B, et al. Pericardial effusion as a sign of acquired hypothyroidism in children with Down syndrome. Eur J Pediatr. 1993; 152:397–398. PMID: 8319703.

14. Gyon YH, Han HS. Massive pericardial effusion and short stature caused by autoimmune hypothyroidism in a 9-year-old girl. Ann Pediatr Endocrinol Metab. 2015; 20:98–101. PMID: 26191514.

15. Sanda S, Newfield RS. A child with pericardial effusion and cardiac tamponade due to previously unrecognized hypothyroidism. J Natl Med Assoc. 2007; 99:1411–1413. PMID: 18229779.

16. da Silva PS, Lau AR. Massive pericardial effusion in a child: an unusual presentation of hypothyroidism. Eur J Emerg Med. 2010; 17:181–182. PMID: 19730106.

17. Rivkees SA, Bode HH, Crawford JD. Long-term growth in juvenile acquired hypothyroidism: the failure to achieve normal adult stature. N Engl J Med. 1988; 318:599–602. PMID: 3344006.

18. Purkait R, Prasad A, Bhadra R, Basu A. Massive pericardial effusion as the only manifestation of primary hypothyroidism. J Cardiovasc Dis Res. 2013; 4:248–250. PMID: 24653591.

19. Taback SP, Dean HJ, Elliott E. Management of short stature. West J Med. 2002; 176:169–172. PMID: 12016239.

20. Berard RA, Laxer RM. Pediatric mixed connective tissue disease. Curr Rheumatol Rep. 2016; 18:28. PMID: 27032791.