Acquired hypothyroidism in an adolescent boy following thyroid surgery
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《美国医学杂志》
1 Department of Pediatrics, Tirur Nursing Home, Tirur,Malappuram District, Kerala, India
2 Medical College, Calicut, Kerala, India
The reported prevalence of acquired hypothyroidism among school-aged children is 0.08% and the most common cause is lymphocytic thyroiditis. Other causes include irradiation to the area of the thyroid, anti-thyroid drugs and malignant infiltrations. Hypothyroidism can occur after thyroidectomy or removal of ectopic thyroid gland. Removal of thyroid tissue of a thyroglossal duct cyst or lingual thyroid may lead to hypothyroidism if there is no other functioning thyroid gland in the body.[1]
We report a case of acquired hypothyroidism following removal of thyroglossal duct cyst. A 17- year-old boy was brought to the casualty with history of one episode of syncopal attack 3 hours prior to consultation. On examination he was pale and had puffy cheeks with thick and pouted lips. He had dry coarse skin and husky voice. Pulse rate was 54/minute, blood pressure 90/56mm.Hg and temperature was normal. His height was 136cm (short stature - below 3 rd percentile) with upper segment- lower segment ratio 0.88:1 and arm span 136 cm. His weight was 27Kg and SMR was stage 2. Abdominal examination showed hard fecal matter. Cardiovascular system examination showed bradycardia, normal heart sounds with no cardiomegaly and no murmur. Nervous system examination revealed delayed relaxation of deep tendon reflexes.
He was born of normal labour and his developmental milestones were within normal limits. At the age of 5 years he had undergone surgery for thyroglossal duct cyst. After surgery he had decreased energy and increased need for sleep. He also gave history of constipation. His academic performance gradually deteriorated and after repeated failures he dropped out from the school.
His blood Hb was 7.58g/dL and peripheral smear showed hypochromic microcytic anemia. Serum cholesterol was 280mg/dL, blood urea 26mg/dL and blood glucose 147mg/dL. Thyroid hormone studies showed very low total T3 and T4 values and elevated TSH level (T3 - 18ngm/dL; T4 - 1.3micr.gm/dL and TSH- 90 micro IU/mL). X-ray wrist and elbow showed significantly delayed osseous maturation. ECG showed low voltage complexes, heart rate of 60 per minute and prolonged PR interval (0.22sec). Ultrasound scanning of the neck showed absent thyroid tissue.
The boy was started on L-thyroxine 100 micrograms per day and gradually increased to 200 micrograms per day. He had regular follow-up and now at the end of one year he is symptom free and his thyroid function tests are within normal limits. He is now preparing for the SSLC examination as a private candidate.
The clinical and laboratory findings in this child were consistent with the diagnosis of hypothyroidism. All symptoms started after the surgical removal of the thyroglossal duct cyst. Ultrasound scanning of the neck region detected no thyroid tissue. The thyroid tissue in the thyroglossal duct cyst may have been functioning as an ectopic thyroid and the only functional thyroid tissue in the body, removal of which resulted in hypothyroidism. A midline ectopic thyroid gland can be misdiagnosed as a thyroglossal duct cyst.[2] There are several reports of the inadvertent removal of an ectopic thyroid gland that was mistaken for a thyroglossal duct cyst, which resulted in profound hypothyroidism.[2],[3],[4] Before surgical removal of thyroglossal duct cyst every effort should be made to localize the thyroid gland. Some authors recommend ultrasound examination as an accurate, cost-effective, non-invasive imaging modality in the preoperative evaluation of all patients with neck masses suspicious of thyroglossal duct cyst.[5], [6] It is suggested that thyroid function tests and a 99mTc or 123 I scintiscan of the neck should be performed when evaluating a patient with a midline anterior cervical mass.[2]
References
1. Lafranchi S. Disorders of thyroid gland: Hypothyroidism. In Behrman. RE, Kliegman. RM, Jenson. HB. Editors. Nelson Textbook of Pediatrics .17th ed. Philadelphia: Saunders; 2004. p. 1877.
2. Conklin WT, Davis RM, Dabb RW, Reilly CM. Hypothyroidism following removal of a thyroglossal duct cyst. Plast Reconstr Surg 1981; 68 : 930-932.
3. Leung AK, WONg AL, Robson WL. Ectopic thyroid gland simulating a thyroglossal duct cyst: a case report. Can J Surg 1995; 38 : 87-89.
4. Holland AJ, Sparnon AL, LeQuesne GW. Thyroglossal duct cyst or ectopic thyroid gland J Paediatr Child Health 1997; 33: 346-348.
5. Gupta.P , Maddalozzo. J. Preoperative Sonography in presumed thyroglossal duct cysts. Arch Otolaryngol Head Neck Surg 2001; 127 : 200-202.
6. Brewis C, Mahadevan M, Bailey CM, Drake P. Investigation and treatment of thyroglossal cysts in children. R Soc Med 2000; 93 : 18-21.(Naushad K, Prasanth, Ravi)
2 Medical College, Calicut, Kerala, India
The reported prevalence of acquired hypothyroidism among school-aged children is 0.08% and the most common cause is lymphocytic thyroiditis. Other causes include irradiation to the area of the thyroid, anti-thyroid drugs and malignant infiltrations. Hypothyroidism can occur after thyroidectomy or removal of ectopic thyroid gland. Removal of thyroid tissue of a thyroglossal duct cyst or lingual thyroid may lead to hypothyroidism if there is no other functioning thyroid gland in the body.[1]
We report a case of acquired hypothyroidism following removal of thyroglossal duct cyst. A 17- year-old boy was brought to the casualty with history of one episode of syncopal attack 3 hours prior to consultation. On examination he was pale and had puffy cheeks with thick and pouted lips. He had dry coarse skin and husky voice. Pulse rate was 54/minute, blood pressure 90/56mm.Hg and temperature was normal. His height was 136cm (short stature - below 3 rd percentile) with upper segment- lower segment ratio 0.88:1 and arm span 136 cm. His weight was 27Kg and SMR was stage 2. Abdominal examination showed hard fecal matter. Cardiovascular system examination showed bradycardia, normal heart sounds with no cardiomegaly and no murmur. Nervous system examination revealed delayed relaxation of deep tendon reflexes.
He was born of normal labour and his developmental milestones were within normal limits. At the age of 5 years he had undergone surgery for thyroglossal duct cyst. After surgery he had decreased energy and increased need for sleep. He also gave history of constipation. His academic performance gradually deteriorated and after repeated failures he dropped out from the school.
His blood Hb was 7.58g/dL and peripheral smear showed hypochromic microcytic anemia. Serum cholesterol was 280mg/dL, blood urea 26mg/dL and blood glucose 147mg/dL. Thyroid hormone studies showed very low total T3 and T4 values and elevated TSH level (T3 - 18ngm/dL; T4 - 1.3micr.gm/dL and TSH- 90 micro IU/mL). X-ray wrist and elbow showed significantly delayed osseous maturation. ECG showed low voltage complexes, heart rate of 60 per minute and prolonged PR interval (0.22sec). Ultrasound scanning of the neck showed absent thyroid tissue.
The boy was started on L-thyroxine 100 micrograms per day and gradually increased to 200 micrograms per day. He had regular follow-up and now at the end of one year he is symptom free and his thyroid function tests are within normal limits. He is now preparing for the SSLC examination as a private candidate.
The clinical and laboratory findings in this child were consistent with the diagnosis of hypothyroidism. All symptoms started after the surgical removal of the thyroglossal duct cyst. Ultrasound scanning of the neck region detected no thyroid tissue. The thyroid tissue in the thyroglossal duct cyst may have been functioning as an ectopic thyroid and the only functional thyroid tissue in the body, removal of which resulted in hypothyroidism. A midline ectopic thyroid gland can be misdiagnosed as a thyroglossal duct cyst.[2] There are several reports of the inadvertent removal of an ectopic thyroid gland that was mistaken for a thyroglossal duct cyst, which resulted in profound hypothyroidism.[2],[3],[4] Before surgical removal of thyroglossal duct cyst every effort should be made to localize the thyroid gland. Some authors recommend ultrasound examination as an accurate, cost-effective, non-invasive imaging modality in the preoperative evaluation of all patients with neck masses suspicious of thyroglossal duct cyst.[5], [6] It is suggested that thyroid function tests and a 99mTc or 123 I scintiscan of the neck should be performed when evaluating a patient with a midline anterior cervical mass.[2]
References
1. Lafranchi S. Disorders of thyroid gland: Hypothyroidism. In Behrman. RE, Kliegman. RM, Jenson. HB. Editors. Nelson Textbook of Pediatrics .17th ed. Philadelphia: Saunders; 2004. p. 1877.
2. Conklin WT, Davis RM, Dabb RW, Reilly CM. Hypothyroidism following removal of a thyroglossal duct cyst. Plast Reconstr Surg 1981; 68 : 930-932.
3. Leung AK, WONg AL, Robson WL. Ectopic thyroid gland simulating a thyroglossal duct cyst: a case report. Can J Surg 1995; 38 : 87-89.
4. Holland AJ, Sparnon AL, LeQuesne GW. Thyroglossal duct cyst or ectopic thyroid gland J Paediatr Child Health 1997; 33: 346-348.
5. Gupta.P , Maddalozzo. J. Preoperative Sonography in presumed thyroglossal duct cysts. Arch Otolaryngol Head Neck Surg 2001; 127 : 200-202.
6. Brewis C, Mahadevan M, Bailey CM, Drake P. Investigation and treatment of thyroglossal cysts in children. R Soc Med 2000; 93 : 18-21.(Naushad K, Prasanth, Ravi)