Thyrotoxicosis in children and adolescents – diagnostic and therapeutic dilemmas

Tirotoksikoza je uzrokovana različitim čimbenicima, a manifestira se šarolikim kliničkim znakovima hipermetaboličkog stanja. Primjeren terapijski pristup ovisi o uzrocima bolesti i bolesnikovom stanju te zahtijeva brzu i pravilnu dijagnostičku obradu. Ovaj članak iznosi pregled liječenja tirotoksikoze zasnovano na klinički utemeljenim podatcima, a donosi i pregled vlastitih iskustava u četrnaestgodišnjem razdoblju. Pregledom literature, posebno različitih smjernica i drugih publiciranih materijala, služeći se PubMed-om, izdvojili smo podatke koje iznosimo u kritičkom tonu. Iskustva u četrnaestgodišnjem liječenju djece i adolescenata s tirotoksikozom u Klinici za dječje bolesti KBC-a Split usporedili smo s iskustvima drugih autora. Klinički opis uključuje početnu kli ničku evaluaciju i dijagnostički pristup tirotoksikozi, uključujući subkliničku hipertireozu, Hashimotovu i Gravesovu bolest. Pristup Gravesovoj bolesti uključuje tirostatske lijekove, terapiju radioaktivnim jodom i operativno liječenje. U našoj ustanovi u četrnaestgodišnjem razdoblju pregledali smo 59-ero bolesnika s tirotoksikozom, Hashimotovu bolest imalo je 17/59 (28,8%) bolesnika, a Gravesovu bolest 41/59 (69,5%), dok je 1/59 (1,7%) imao rijetki nedostatak TBG-a (engl. Thyroxine Binding Globulin). Remisiju bolesti doživjelo je 12/41 (29,2%) bolesnika s Gravesovom bolešću, a relaps 4/12 (33,3%). Terapija radioaktivnim jodom primijenjena je u 3/41 (7,3%), a operacija u 13/41 (31,7%) bolesnika s Gravesovom bolešću. Doneseno je više preporuka i zaključaka na utemeljenim kliničkim podatcima racionalnog, pouzdanog i optimalnog kliničkog pristupa oboljelima od tirotoksikoze. Odabir načina liječenja Gravesove bolesti složen je proces. Razgovor o prednostima i rizicima predloženih terapijskih mjera s bolesnikom i njegovim roditeljima je nužan. U našoj ustanovi preporuča se poticati roditelje bolesnika s Gravesovom bolešću koji imaju malu mogućnost za postizanje remisije na bržu odluku o defi nitivnom liječenju.Thyrotoxicosis is caused by diff erent etiologic factors and is manifested by various clinical signs of hypermetabolism. Appropriate therapeutic approach demands prompt and correct diagnosis and depends on the cause and condition of the patient. This article presents a clinical review of thyrotoxicosis treatment based on clinically acquired data and brings a review of personal experiences during a 14-year period. We searched the literature, on PubMed and other published materials. We compared our experience at Clinical Department of Pediatrics, Split University Hospital Center, with experiences of others. Clinical description includes initial evaluation and approach to thyrotoxicosis; subclinical hyperthyroidism/thyrotoxicosis; Hashimoto’s and Graves’ disease, and approach to Graves’ hyperthyroidism including antithyroid drugs, radioactive iodine and surgical treatment. During the 14-year period, we examined 59 patients with thyrotoxicosis, including 7/59 (28.8%) patients diagnosed with Hashimoto’s disease, 41/59 (69.5%) patients diagnosed with Graves’ disease, and 1/59 (1.7%) patient diagnosed with rare thyroxine binding globulin (TBG) insuffi ciency. Twelve of 41 (29.2%) patients with Graves’ disease had remission and relapse occurred in one-third (n=4) of these 12 (33.3%) patients. Radioiodine therapy was used in 3/41 (7.3%) patients with Graves’ disease, whereas 13/41 (31.7%) patients underwent surgical operation. Many recommendations and conclusions have been drawn on the basis of clinical data on the rational, safe and optimal medical approach to patients with thyrotoxicosis. Choosing treatment for Graves’ disease is a complex process. Discussing advantages and risks of recommended therapies with patients and parents is desirable and necessary. In our institution, it is necessary to encourage parents of Graves’ disease patients with minor chance of remission to make quick decision on defi nitive care