State establishment «dnepropetrovsk medical academy of ministry of health ukraine»
Criteria of an assessment of severity of iodine deficiency
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- Bu səhifədəki naviqasiya:
- 3 . Clinical criteria of diagnostics
- Materials for self-checking: Situational clinical tasks Case 1
- B. Tests Question 1
2. Criteria of an assessment of severity of iodine deficiency
3 . Clinical criteria of diagnostics (examination is performed on an outpatient basis): - Anamnesis: residence in the endemic area. - Palpation of thyroid: painless, soft and elastic, mobile, surface equal. 4 . Paraclinical criteria of diagnostics - ultrasound of thyroid gland (at goiter identification of ІІ degree or nodal forms).
- changes of echo-density – increased or decreased, - rough granularity, frequent with small cystous inclusions.
- presence of volume formation (one or several) with the expressed capsule. Euthyroid goiter: - Clinical manifestations are absent if there is small increase in thyroid gland. - The severety of symptoms depends upon the size of the thyroid: - Discomfort (unpleasant feelings) in the neck. - Feeling of pressure in the neck, more expressed at inclinations. - Unpleasant feelings when swallowing. - Difficulty of breathing. Hormonal researches: normal TTH, T4. Hypothyroidal goiter: Subclinical hypothyroidism: - Complaints are absent - The diagnosis is established at the level TTH >2,0 mU/l and normal T4 level. Manifest hypothyroidism: see the hypothyroidism protocol
Treatments it is carried out on an outpatient basis on purpose: - reduction and normalization of volume of thyroid gland; - maintenance of euthyroidism A.Treatment of endemic euthyroid goiter: 1 . Preparations of potassium iodine: - children younger than 6 years - 100 mcg once a day, from 6 to 12 years - 150 mcg once a dayolder than 12 years - 150-200 mcg once a day, - In the absence of effect (if after 6 months of treatment the goiter isn't decrease or decreases less, than at 50%) to add combined therapy: potassium iodine 100 mcg/day + L-thyroxin 50-100 mcg (starting from the dose 25 mcg once a day in the morning, with gradual increase in the dose once a week on 25 mcg till the full dose). 2 . At the goiter of ІІ and ІІІ degree to begin treatment from the combination of preparations: Potassium iodine 100 mcg/day + L-thyroxin 50-100 mcg. 3 . Together with L-thyroxin - products enriched with calcium or calcium preparations in age dose. Duration of the course of treatment while using each from three schemes has to be in duration 6 months - 2 years till normalization of thyroid size. Further at normalization of volume of thyroid gland for the prevention of goiter recurrence - continuous iodine prevention B. Treatment of an endemic goiter with hypothyroidism: L-thyroxin - constantly (see the hypothyroidism protocol). Criteria of efficiency of treatment of an endemic goiter with hypothyroidism: - achievement of euthyroidism: - absence of clinical manifestations of a hypothyroidism, - optimum level of TTH 0,4-2,0 mU/l with the control 1 month after initiation of treatment, further, after full dose administration - 1 time per 3 months. - normal volume of thyroid gland (control of ultrasound investigation 1 time per 6 months)
- nodal forms of a goiter (solitary nodes, multi-nodal goiter): -presence of signs of the compression by the goiter of organs located at the neck; - sizes of nodes more than 3 cm, cosmetic defect or desire of the patient to operate; - cytologic signs of the cancer of the thyroid gland, or the suspicion of it (by clinical symptoms)
- Reduction or normalization of the size of thyroid gland by ultrasound investigation (control of ultrasound 1 time per 6 months). - Maintainance of euthyroidism (TTH within 0,4-2,0 mU/l)
1 . Massive iodine prevention at population level - continuous use by the population of the iodated food salt and food products which contain iodine. Group and individual iodine prevention - the organized administration of drugs which contain potassium iodine in the corresponding dose: - infants receive iodine with breast milk; - for children till 6 years - potassium iodine of 90 mcg once a day; - children 6-12 years -120 mcg of potassium iodine once a day; - older than 12 years - 150 mcg of potassium iodine once a day; - at pregnancy and during breastfeeding: 200 mcg of potassium iodine once a day. 2 . Prevention of recurrence of the goiter after operation of nodal endemic goiter - potassium iodine of 100-200 mcg once a day for 6 months. 3 . Sanitation of the centers of chronic inflammatory processes 7 . Dispensary supervision lifelong.
Case 1 A 10-week-old boy is referred to the endocrinology service for evaluation of abnormal thyroid function. His mother is a 26-year-old primigravida whose pregnancy was complicated by hyperthyroidism and mild, untreated hypertension. She had a history of goiter, and at 7 weeks’ gestation was diagnosed as having Graves disease (thyrotropin [TSH]-independent hyperthyroidism), with an elevated total thyroxine (T4) level of 29.8 mcg/dL (383.5 nmol/L) and an undetectable TSH level of less than 0.03 mcIU/L. Propylthiouracil (PTU) and a long-acting beta-adrenergic blocker were administered, and her symptoms decreased after 1 month. Thyroid function was followed through the pregnancy, and her medication was adjusted. Despite several increases, she remained significantly hyperthyroid until the 33rd week of gestation. The infant was born at 38 weeks’ gestation, having a birthweight of 2,636 g (5.76 lb). He had mild jaundice. Newborn screening revealed a low total T4 level at 3.1 mcg/dL (39.9 nmol/L) (normal, 8.2 to 19.9 mcg/L [105.5 to 256.1 nmol/L]) and a normal TSH level of 2.2 mcIU/L (normal, 1.3 to 16.0 mcIU/L). The baby was lost to follow-up until age 10 weeks, at which point his free T4 level was still low at 0.8 ng/dL (10.3 pmol/L), and he was referred. On referral at 10 weeks, the baby is taking 4 oz of formula every 2 to 3 hours and having one well-formed stool daily. His blood pressure is 99/44 mm Hg, pulse is 156 beats/min, length is 56.4 cm (10th percentile), weight is 5.1 kg (25th percentile), and head circumference is 38.0 cm (10th percentile). Physical findings include an anterior fontanelle measuring 1.5 x 1.5 cm; closed posterior fontanelle; slightly blue-tinged sclerae; normal tongue; no goiter or lingual masses; and a small, reducible umbilical hernia. Further evaluation revealed that the thyroxine-binding globulin (TBG) level was normal at 2.5 mg/dL (25 mg/L) (normal, 2.1 to 6.0 mg/dL [21 to 60 mg/L]), triiodothyronine resin uptake (T3RU) was normal at 37.3% (0.373) (normal, 27% to 40% [0.27 to 0.40]), and thyrotropin-binding inhibitory immunoglobulins (TBII) were elevated at 16.2% (0.162) (normal, <10% [0.10]). On referral of the patient at age 10 weeks, levothyroxine for thyroid replacement was initiated at 25 mcg/d. Follow-up levels documented improvement. The family «ran out» of levothyroxine after 7 weeks and did not keep follow-up appointments. When they did return, the baby`s thyroid function levels were normal.
Case 2 A 19-month-old boy who has a past history of intestinal obstruction presents with chronic constipation. He immigrated recently to the United States from Jamaica, where he was born at term via spontaneous vaginal delivery. Pregnancy and delivery were uncomplicated. There was no drug or alcohol use during pregnancy. By a few weeks of age, he developed a weak cry, relative inactivity, poor feeding, and intermittent abdominal distension and constipation. At 5 months of age, he had an ileostomy created because of an intestinal obstruction of unknown cause. Infection and poor healing of the surgical incision complicated his postoperative course. Since surgery, he has had slow growth and weight gain and chronic constipation. He does not sit unsupported or crawl. There is no history of recurrent upper or lower respiratory tract infections. Goiter is reported in two second-degree relatives. On physical examination, the patient’s weight is 5.5 kg, height is 58.8 cm, and head circumference is 43 cm. He has wide-spaced anterior and posterior fontanelles and sutures; thinning, brittle hair; a flat, broad nasal bridge; bilateral eyelid edema; and absent teeth. The abdominal examination reveals a large incisional hernia with significant scarring. The extremities are dry and mottled, with nonpitting edema of the hands and feet. The infant has a coarse cry, and his truncal tone and deep tendon reflexes are diminished. Radiologic examination of the left hand reveals a bone age of newborn to 3 months, with evidence of epiphyseal dysgenesis. Questions
Case 3 A 17-year-old boy is evaluated because of declining school performance. Although he was an honor student while working a part-time job 6 months ago, he now is at risk of failing several of his classes. The boy and his parents cannot pinpoint a precise cause for his recent decline, but the parents express concern that now he is "hanging around with the wrong crowd." Without his parents present, the boy denies drug or alcohol use or a history of physical abuse. His past medical history reveals allergic rhinitis. His only medication is a nonsedating antihistamine. Family history includes allergic rhinitis, asthma, and maternal hyperthyroidism. According to the patient, the review of systems is completely negative, but his parents report that he is more fatigued than usual, somewhat irritable, and sleeping poorly. On physical examination, he is a tall, thin adolescent male who has normal vital signs. Besides his obvious "allergic shiners" and slight fullness of the anterior neck, results of his physical examination are unremarkable. Due to his unexplained academic decline and behavior changes, laboratory studies are obtained that reveal the cause of his failing grades. Due to the family history of thyroid disease, thyroid-stimulating hormone (TSH) was measured and found to be undetectable. The total thyroxine (T4) concentration was 18.2 mcg/dL (234.2 nmol/L) (normal, 5 to 12 mcg/dL [64.4 to 154.4 nmol/L]), and antithyroid antibodies were present. A thyroid uptake scan revealed a mildly enlarged, homogenous gland that displayed marked uptake. Questions.
B. Tests Question 1. Physical findings in Graves disease include all of the following except: A. Motor hyperactivity B. Cold intolerance C. Tremor D. Weight loss E. Tachycardia F. Smooth, flushed, warm skin
A. Higher incidence in females B. Incidence of 1:4,000 C. Lower incidence in African-Americans D. Central role of thyroid peroxidase antibodies E. Absence of symptoms at birth Answer D. Explanation: These autoantibodies have a minor role, if any, in the etiology of this disorder. However, thyroid gland growth blocking and cytotoxic antibodies may have a role in the etiology of congenital hypothyroidism. Question 3. A 6-wk-old infant has gained no weight since birth. Her skin appears mottled, and an indirect bilirubin level is measured at 24 mg/dL. Her extremities are cold, and her temperature is 35oC. The most likely diagnosis is: A. Kernicterus B. Sepsis C. Galactosemia D. Hypothermia E. Hypothyroidism Answer E. Explanation: Congenital hypothyroidism may also demonstrate large fontanels, feeding intolerance, distended abdomen, constipation, prolonged sleep, and a poor cry. Question 4. The evaluation of the child described in Question 42 is best accomplished by: A. Serum TSH determination B. Serum T4 assay C. Bone age determination D. Head CT E. Thyroid scan Answer B. Explanation: The serum T4 is markedly depressed. Most cases of congenital hypothyroidism are due to dysgenesis of the thyroid gland, and therefore the TSH is elevated and a thyroid scan shows no uptake or ectopic tissue. Nonetheless, the serum T4 is the best of these tests. Central hypothalamic pituitary causes have a low TSH. Therapy with T4 should be initiated immediately. Fortunately, state screening for congenital hypothyroidism has prevented this type of late presentation with the inherent risks of mental retardation. Question 5. A 14-yr-old girl presents with poor growth and delayed puberty. She denies headaches or poor school performance. She is physically sluggish and has a small goiter, and her serum cholesterol is 500 mg/dL. The most likely diagnosis is: A. Hashimoto disease B. Graves disease C. Congenital hypothyroidism D. Familial type II hyperlipidemia E. Pituitary prolactinoma Answer A. Explanation: Hypothyroidism that is acquired is insidious in onset and primarily affects growth. Schoolwork is not as severely affected, as one would expect. Question 6. Common features of Graves disease include all of the following except: A. A 5:1 male:female ratio B. A 6-mo to 1-yr delay in diagnosis C. Emotional disturbances D. Poor school work E. Tremors F. Voracious appetite G. Exophthalmos Answer A. Explanation: The female:male sex ratio is actually 5:1. Question 7. A 3,600-g, breast-fed, white girl with a gestational age of 42 wk is noted to have persistent hyperbilirubinemia at 2 wk of age. On physical examination, the infant is found to have not gained weight since birth; she has decreased tone, an umbilical hernia, and an anterior fontanel measuring 4 x 6 cm. The most likely diagnosis is: A. Crigler-Najjar syndrome B. Gilbert disease C. Biliary atresia D. Hypothyroidism E. Galactosemia Answer D. Explanation: Hypothyroidism was confirmed by the late arrival of the newborn screening results, indicating high TSH and low T4 levels. Treatment with thyroxine improved the jaundice and the other signs. The hyperbilirubinemia is indirect (unconjugated). Crigler-Najjar syndrome is a possibility and is either autosomal dominant or recessive (check the family history). However, there are signs other than jaundice that suggest another disease. Biliary atresia is always a concern in infants with delayed clearance of jaundice or worsening jaundice after 2 wk of life. The hyperbilirubinemia is predominantly direct (conjugated). Galactosemia should be considered, especially in the presence of hypoglycemia, directreacting jaundice, hepatomegaly, or ascites. Question 8. An 8-year-old boy has short stature. He has begun to gain quite a bit of weight over the last year, has little or no energy, sleeps more than normal, and complains of being cold. His growth curve demonstrates that he has fallen from the 50th percentile to the 5th percentile for height, but his weight has increased to the 90th percentile. On examination, he is obese, has an immature facies, thin hair, and slow reflexes. Which of the following is the most appropriate course of action for this child? A. Order Epstein-Barr virus titers. B. Measure thyroid function. C. Reassure the mother that the child has normal prepubertal development. D. Determine bone age. E. Order a somatomedin C level. Answer B. This child has classic symptoms of acquired hypothyroidism. A bone age would be delayed, but thyroid function studies are needed to make the diagnosis. Thyroid hormone replacement therapy should resolve these symptoms, and growth should resume normally. Question 9. A 12-year-old girl has a mass in her neck. Physical examination reveals a thyroid nodule, but the rest of the gland is not palpable. A technetium scan reveals a “cold” nodule. The child appears to be euthyroid. Which of the following diagnoses is the least likely? A. Simple adenoma B. Follicular carcinoma C. Papillary carcinoma D. Cyst E. Dysgenetic thyroid gland The answer is E. A dysgenetic thyroid gland can appear as a neck mass; as a rule, however, it is functional and, thus, does not appear as a cold nodule on thyroid scan. A cold thyroid nodule can be a benign or malignant lesion. With the exception of anaplastic carcinomas, most thyroid malignancies are slow-growing. The incidence of thyroid malignancy in children appears to be decreasing, possibly as a result of a decrease in the exposure of children to x-rays. Question 10. You are evaluating a small-for-gestational-age infant for tachycardia. There is no prenatal care history available, but based on the infant’s signs and symptoms and the obstetrician’s description of the mother you suspect neonatal thyrotoxicosis. Thyrotoxicosis in the first day of life most likely occurs in an infant born to a mother with which of the following diagnoses? A. with untreated hypothyroidism B. with untreated Graves disease C. with Graves disease being treated with antithyroid medications D. with euthyroid goiter E. receiving iodides as therapy for chronic bronchitis
at birth, presumably as a result of transplacental passage of thyroid-stimulating antibodies. These antbodies can cause an increase in fetal thyroid hormone production. If the mother is receiving antithyroid medication, this also crosses the placenta, and the infant may be euthyroid or even hypothyroid at birth. Even if the infant is asymptomatic at birth, the antibodies may persist for several weeks so regular screeing of the infant’s thryoid function during the first 4–6 weeks of life is indicated. Question 11. A 12-year-old girl applied to doctor with complaints of swelling on the front part of the neck. The doctor diagnosed hyperplasia of the thyroid gland of the second degree, euthyroidism. Ultrasound suspected autoimmune thyroiditis. Blood was taken for titre of antibodies to thyroglobulin. What titre of antibodies will be diagnostically important?
This condition was regarded as a pubertal manifestation, the girl didn't undergo any treatment. The girl's irritability gradually gave place to a complete apathy. The girl got puffy face, soft tissues pastosity, bradycardia, constipations. Skin pallor and gland density progressed, the skin became of a waxen hue. What disease may be suspected? A Autoimmune thyroiditis B Diffuse toxic goiter C Thyroid carcinoma D Subacute thyroiditis E Juvenile basophilism Question 13. A 2 m.o. child with birth weight 5100 g has jaundice, hoarse cry, umbilical hernia, physical development lag. Liver is +2 cm enlarged, spleen is not enlarged. In anamnesis: delayed falling-away of umbilical cord rest. In blood: Hb- 120 g/L, erythrocytes - 4,5\10^12}/L, ESR- 3 mm/h. Whole serum bilirubin is 28 mcmole/L, indirect - 20 mcmole/L, direct - 8 mcmole/L. What is the most probable diagnosis? A Congenital hypothyreosis B Congenital hepatitis C Hemolitic anemia D Conjugated jaundice E Cytomegalovirus infection Question 14. Examination of a 12 year old child revealed diffuse thyroid enlargement of the II degree. Heart auscultation revealed dullness of heart sounds, heart rate was 64/min. The child has frequent constipations, anemia. Concentration of thyreoglobulin antibodies is increased. What disease might have caused such symptoms?
heart pain, fatigue. Hyperplasy of thyroid gland of ІІ degree, exophthalmus are noted. What hormonal disorders are most typical at this disorder? A Increase of thyroxine and triiodethyronine B Increase of thyreothropine C Increase of the iodine connected with protein D Decrease of thyroxine E Decrease of triiodethyronine
B Thyrotoxicosis C Iodine insufficiency D Congenital intestine disorder E Malabsorbtion
1. Nelson Textbook of Pediatrics. - 18th ed. / Ed. by R. Kliegman et al.-Philadelphia: Saunders Co, 2007.- 3146 p. 2. Pediatry. Guidance Aid / За ред. О.В. Тяжка; О.П. Вінницька, Т.І. Лутай – К. : Медицина, 2007 . – 158 с. 3. Practical pediatrics. - 5th ed. / Ed. by M.J.Robinson, D.M.Roberton – Elsevier. – 2003. 4. Rapid paediatrics / Ed. by Helen Brough ... [et al.]. - Blackwell Publishing Ltd. – 2004. 5. Clinical Pediatric Endocrinology - 5th ed. / Edited by Charles G.D. Brook et al. - Blackwell Publishing Ltd – 2005. 6. Handbook of Clinical Pediatric Endocrinology - 1st ed. / Edited by Charles G.D. Brook, Rosalind S. Brown. - Blackwell Publishing Ltd. – 2008. Performed by assistant Linnik V.A., assistant Tkachenko N.P. Approved “_____”____________20____y. Protocol №_____ Сhief of the department, professor V. A. Kondratyev Reconsidered Approved “_____”____________20____р. Protocol №_____ Сhief of the department, professor V. A. Kondratyev
Approved ““_____”____________20____р. Protocol №_____ Сhief of the department, professor V. A. Kondratyev
Approved “_____”____________20____р. Protocol №_____ Сhief of the department, professor V. A. Kondratyev
Approved ““_____”____________20____р. Protocol №_____ Сhief of the department, professor V. A. Kondratyev
Approved “_____”____________20____р. Protocol №_____ Сhief of the department, professor V. A. Kondratyev
Approved ““_____”____________20____р. Protocol №_____ Сhief of the department, professor V. A. Kondratyev Yüklə 274,5 Kb. Dostları ilə paylaş:
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