A 13-Year-Old Girl With Fever After Travel

Colleen Mathis, MD; Kimberly Monroe, MD, MS


October 30, 2020


The patient's screening thyroid studies revealed a thyroid-stimulating hormone (TSH) level < 0.01 mIU/L, free triiodothyronine (T3) level > 20 pg/mL, and total thyroxine (T4) level > 29 µg/dL. Upon repeat examination, she was found to have a mildly enlarged diffuse goiter, which was previously unrecognized.

Hyperthyroidism in children and adolescents is relatively rare, occurring in 0.1-3 per 100,000 children; 95% of these patients are diagnosed with Graves disease.[1,2] As seen in the patient in this case, Graves disease is more common among females, with a peak incidence at age 10-15 years.[1] Graves disease involves the infiltration of lymphocytes into the thyroid gland and production of stimulating autoantibodies to the TSH (thyrotropin) receptor. These thyroid-stimulating immunoglobulins (TSIs) mimic the action of TSH, causing uninhibited production and release of thyroid hormones. This results in increased T3 and T4 levels and suppression of TSH.[1,2,3]

Patients typically present with weight loss, frequent stools, fatigue, palpitations, dyspnea, anxiety, emotional lability, and warm, moist skin.[3] Signs and symptoms of hyperthyroidism are similar in children and adolescents to those in adults. However, a considerable delay in diagnosis often occurs in children, ranging from 5 months in pubertal children to 8 months in prepubertal children.[2] Often, behavioral disorders, including attention-deficit/hyperactivity disorder or anxiety, respiratory diseases (eg, exercise-induced asthma), or primary cardiac diseases, are considered rather than hyperthyroidism as the cause of the symptoms.


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