Pediatric Graves Disease - Causes, Symptoms, Diagnosis, and Treatment

What Is Graves Disease?

Graves disease is an autoimmune disorder where there is excess secretion of the thyroid hormone. Generally, the immune system produces antibodies to fight against bacterial, viral, or other foreign body invasions. But in the case of autoimmune diseases, the body fails to produce the antibodies, thus attacking its own body tissues. Similarly, in Graves disease, the antibodies are produced to stimulate the thyroid gland resulting in increased levels of thyroid hormones, and the condition is referred to as hyperthyroidism. These hormones enter the bloodstream, thus increasing the metabolism of the body. It may result in weight loss, nervousness, etc. The children affected by this condition may require lifelong follow-ups.

What Are the Other Names of Graves Disease?

• Toxic diffuse goiter.

• Autoimmune hyperthyroidism.

• Exophthalmic goiter.

• Basedow’s disease.

How Common Is Graves Disease?

• Graves disease affects about 1 in 10,000 children, and it is seen to affect 1 in 1000 adults.

• It has got a female predilection. So there are chances for life-term risks in females.

• Graves disease is, however, not frequently encountered in children.

What Is the Thyroid?

The thyroid is a small butterfly-shaped gland located in the front of the neck. It is responsible for producing the hormones thyroxine (T4) and triiodothyronine (T3). It serves three primary functions

• Regulation of the metabolic rate of the body.

• Regulates and controls the functioning of the heart, muscles, and digestive system.

• It plays a vital role in brain and bone development.

What Causes Graves Disease in Children?

The exact cause is unknown, but genetic predisposition, environmental triggers like stress, infection, and hormonal imbalances contribute to the disease. Certain environmental factors like smoking during pregnancy or early childhood may increase the risk for the development of the disease. Graves disease is a triad that includes:

• Hyperthyroidism: Hyperactive thyroid gland and increased secretion of thyroid hormones.

• Ophthalmopathy: It is characterized by upper eyelid retraction with swelling, redness, and conjunctivitis.

• Dermopathy: Presence of small lesions or spots on the skin.

Generally, Graves disease is less common in children. In Graves disease, the body's disease-fighting immune system malfunctions and produces antibodies against the thyroid gland cells. The exact cause is unknown. However, Graves disease results when the antibodies produced cause the thyroid gland to grow larger and produce more thyroid hormones. Although uncommon in children, it accounts for the majority of hyperthyroid cases in the pediatric population.

What Are the Associated Risk Factors?

• Females are at a higher risk for hyperthyroidism.

• Any family history of Graves disease or other autoimmune thyroid disorders.

• In children, deprivation and neglect may also cause hyperthyroidism.

• Infections.

What Are the Clinical Manifestations of Graves Disease?

Graves disease may have a varied clinical presentation in each case. It varies in children and adults. However, the most common signs and symptoms are:

• Enlargement of the gland in the front of the neck, which is called a goiter.

• Difficulty in swallowing.

• Protrusion or bulging of the eyeballs.

• Severe weight loss due to increased metabolism.

• Increased appetite.

• Increase in blood pressure.

• Increase in the heart rate with rapid heartbeats.

• Excessive sweating.

• Lethargy and weakness.

• The children always seem to be fussy, crying and screaming with irritability.

• Difficulty sleeping.

• Intolerance to heat and warm weather.

• Increased bowel movements and diarrhea.

• Increased frequency of urination. Bedwetting is seen in children.

• Tremors and muscle weakness.

• Swelling of the metacarpals is referred to as osteopathy or thyroid acropachy.

• Problems associated with the eye, such as eyelid retraction and periorbital edema.

What Are the Other Similar Conditions?

Certain conditions appear similar to Graves disease. They are:

• Anorexia nervosa.

• Crohn’s disease.

• Pediatric attention deficit hyperactivity disorder.

• Pediatric bipolar affective disorder.

• Pediatric pheochromocytoma.

How Is Pediatric Graves Disease Diagnosed?

The diagnosis of Graves disease in children may be challenging since they are mostly hyperactive while engaged in play. It is often misdiagnosed as other psychiatric conditions or mental disorders such as attention deficit deficiency disorder, conduct disorders, etc. So keen observation is required before confirming the diagnosis of Graves disease in children. The clinician suspects the condition based on the history obtained. However, certain diagnostic procedures may be required to confirm the diagnosis.

• Blood Investigation: Certain parameters in the blood are checked to know the exact cause of the disease.

• Thyroid Stimulating Hormone Test: A blood test is performed to assess thyroid-stimulating hormone (TSH) levels. Low levels of TSH are suggestive of hyperthyroidism.

• Antibodies Test: Certain antibodies are seen in the proteins of the thyroid gland. Increased antibody levels suggest Graves disease or any other autoimmune thyroid dysfunctions.

• Complete Blood Count: Microcytic anemia is seen in hyperthyroidism.

• Other Blood Examinations: The other specific findings for hyperthyroidism are hypercalcemia, Low levels of low-density lipoproteins (LDL) and high-density lipoproteins (HDL), and high transaminases.

• Total T4 (Thyroxine) and T3 (triiodothyronine) Test: Elevated levels of T4 and T3 confirms the diagnosis of hyperthyroidism.

• Thyroid Ultrasound: It shows increased vasculature to the gland. A hypervascular thyroid gland is seen in Graves disease.

• Pediatric Computed Tomography and Magnetic Resonance Imaging Test: These imaging tests of the eye are recommended to differentiate Graves disease with orbitopathy from hyperthyroidism.

How Is Graves Disease Treated?

The treatment modality varies according to the age of the child, the severity, and the associated medical conditions. The common treatments encountered are:

• Antithyroid Medicines: These medications are given to block thyroid hormone production. The most common medication prescribed for a pediatric patient is Methimazole, as Propylthiouracil is not indicated due to the high chance of liver failure.

• Radioactive Iodine: It is recommended as an alternative to antithyroid drugs if the child is allergic or does not respond to the medication. It also blocks the production of the thyroid hormone. In addition, it destroys some parts of the thyroid glands.

• Surgical Intervention: Surgery is the final option when the child does not respond to any of the conservative therapies. Thyroidectomy is a surgical procedure where a portion of the thyroid gland is removed. In some severe cases, the entire gland may also be removed, followed by lifelong thyroid medications to maintain the hormone levels in the body.

• Glucocorticoid Therapy: It is indicated only in cases of severe ophthalmopathy.

Is There Any Prevention for Graves Disease?

Graves disease is an autoimmune disorder. Therefore there are no ways that could prevent the condition from occurring.

Conclusion:

Graves disorder affects several body parts that may require lifelong monitoring. Generally, parents of the affected children are given prior counseling and reassured about the lifelong follow-ups for the child. It improves the survival rate and the quality of life of the child. However, parents need not worry about the child's health, as several advanced treatments can cure the disease. Although regular follow-ups are mandatory, these children can lead a normal life, engage in regular activities, and work like their counterparts.