Care Of Children And Adolescents With Graves' Disease In An Endocrinological Center

Background Graves' disease is rare in childhood and adolescence. While the criteria for diagnosis are clearly defined, there are controversial discussions in the literature regarding the optimal treatment modality. Objective The aim of the study was to retrospectively analyze the treatment and long-term course of patients with Graves' disease who were under the care of this outpatient department of pediatric endocrinology between 2000 and 2015. Material and methods The data of 50 children and adolescents (40 female, 10 male) aged between 4.5 and 17.6 years (median 12.4 years) were evaluated. The patient history, height, weight and laboratory values were documented at the initial presentation and at every outpatient visit. The duration to achievement of euthyroidism (remission), the time until attempted withdrawal, the duration of remission, the time of recurrence and the time and type of a final treatment were also documented. To calculate thyroid volume (SDS) values, the data of Kromeyer-Hauschild et al. were used as references for height and BMI and for the sonographically measured thyroid volume the data of the German National Health Examination Survey for Children and Adolescents (KiGGS) were used. Results (median values) The diagnosis was made 6 months after the onset of symptoms at the age of 12.4 years. Serum thyroid-stimulating hormone (TSH) levels were suppressed, free tri-iodothyronine (fT(3), 21.6 pmol/l; normal range 3.5-8.1), free thyroxine (fT(4), 48.3 pmol/l; 7.6-17.7), and TSH-receptor antibody (TRAB, 9.4 U/l; <1.5) were elevated. At diagnosis 28 children had goiter (+5.9 SDS) and 15 patients developed a goiter during the further course. All patients primarily received thiamazole (n = 34) or carbimazole (n = 16) and 18 patients a beta blocker. During the course 96% received dual therapy (antithyroid drug plus L-T4) and 9 patients are still receiving primary treatment. Thus, 41 patients could be assessed with respect to the long-term course. The treatment did not affect the size of the thyroid gland. A withdrawal trial was performed in 33 patients at 32 months, including 6 patients receiving treatment for <24 months and 11 patients receiving treatment for more than 36 months. Thyroidectomy was performed in 8 patients on drug treatment without a withdrawal trial due to the increasing goiter. After the end of the thyrostatic therapy, 17 patients achieved full remission (no recurrence of hyperthyroidism after completion of drug treatment) and 8 patients currently have a remission duration >= 12 months. Recurrence treatment was initiated in 7 patients after the first remission and 9 patients underwent thyroidectomy. Conclusion The high remission rate was positively correlated with the treatment duration. The dual therapy regimen might also affect the outcome. The size of the thyroid gland was unchanged during treatment. The extent of TRAB levels at the time of the withdrawal trial did not affect the long-term outcome. In all cases with a rapid goiter progression, an early thyroidectomy should be performed.