An Infant Case of Graves' Disease with Ophthalmopathy

Abstract

Abstract. Graves' disease is a rare disorder in children, particularly in infants. Ocular manifestations of Graves' disease in children are even more rare and are mild compared to adults. We report a 3-year-old girl with Graves' ophthalmopathy who visited our clinic because of lacrimation. Her family had also noticed exophthalmos, goiter, irritability and increased appetite for more than 3 months. The ophthalmologist noted bilateral proptosis, eyelid erythema, lacrimation, entropion of the lower eyelid, and superficial keratitis. Her serum concentrations of free thyroxine and free triiodothyronine were high, and thyroid-stimulating hormone (TSH) was low. Serum samples were markedly positive for antibodies to TSH receptor (TRAb) and thyroid-stimulating antibody (TSAb). Although hyperthyroidism was controlled with propylthiouracil within 3 weeks, her eye signs did not improve. We administered methylprednisolone pulse therapy for ophthalmopathy, but the effect was limited and the lacrimation due to entropion and superficial keratitis persisted. Titers of both TRAb and TSAb decreased slightly and transiently with the pulse therapy. One year later, both titers remained high and eye signs did not improve any more though she was clinically euthyroid. This might indicate that both TRAb and TSAb levels correlate with the clinical course. Therefore, TRAb or TSAb might be good indicators of progress of Graves' ophthalmopathy. Ocular manifestations of Graves' disease should be followed closely with measurements of both TRAb and TSAb even in infant cases.

Clinical Relevance of Thyroid-Stimulating Autoantibodies in Pediatric Graves' Disease—A Multicenter Study

“…In addition to being a useful biomarker for disease activity, TSAb also correlated with the presence of GO independent of thyroid function, suggesting a possible causal role of TSAb in the immunopathogenesis of GO and in the development of the clinical phenotype of thyroid eye disease with proptosis. Similar findings have been reported recently in adults with GD and GO (24,25) and in a case report of an 11 year old girl in whom GO and positive TSAbs preceded by 3 months the development of hyperthyroidism (26). In addition, the present TSAb bioassay proved to be more sensitive in the diagnosis of untreated pediatric GD than a commonly used automated third generation binding assay.…”

A 3-year-old girl with Graves' disease with literature review

“…Indications for radical treatment in children include ATD toxicity, relapse after an appropriate course of drug treatment, and a lack of compliance on the part of the patient or the parents 15) . In reports we have seen 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13) , all the patients were treated with ATD initially. There was one case report of successful radioiodine treatment in a 3-year-old child with Graves' disease following ATD-induced neutropenia 7) .…”

“…There are several reports abroad of Graves' disease in children younger than 4 years 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13) , but no such case has yet been reported in Korea. We report this child because of the rarity, the remarkable ophthalmopathy.…”