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Recognition and Management of Pediatric Thyroid Emergencies in the Emergency Department

Recognition and Management of Pediatric Thyroid Emergencies in the Emergency Department

Recognition and Management of Pediatric Thyroid Emergencies in the Emergency Department

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  About this Issue

Thyroid disease can be difficult to diagnose in the ED, not only because it is uncommonly seen, but because the variety of presentations is wide. Nonetheless, the ED provides an ideal setting to diagnose and arrange for treatment of thyroid disease. This issue reviews common presentations of various thyroid diseases and provides evidence-based recommendations for the management of patients with these diseases. You will learn:

•  Causes of hypothyroidism and hyperthyroidism
•  Common manifestations of hypothyroidism, myxedema coma, hyperthyroidism, Graves disease, thyroid storm, thyroid nodules, and thyroid trauma
•  When additional testing beyond TSH, T4, and T3 is necessary, and which tests are recommended for identifying different thyroid disorders
•  Management of patients with myxedema coma, thyroid storm, and thyroid trauma
•  Which patients can be discharged with referral for further evaluation and treatment, and which patients need surgical consultation or admission

  Issue Information

Authors: Troy W. S. Turner, MD, FRCPC

Peer Reviewers: Derya Caglar, MD, FAAP; Richard M. Cantor, MD, FAAP, FACEP

Publication Date: July 1, 2018

CME Expiration Date: July 1, 2021

CME Credits: 4 AMA PRA Category 1 CreditsTM, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.

PubMed ID: 29949705

  Issue Features
  Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
  6. Differential Diagnosis
    1. Hypothyroidism
      1. Congenital Hypothyroidism
      2. Acquired Hypothyroidism
      3. Myxedema Coma
    2. Hyperthyroidism
      1. Thyroid Storm
    3. Thyroid Nodules
      1. Trauma to the Thyroid Gland
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. Hypothyroidism
    2. Hyperthyroidism
    3. Thyroid Storm
    4. Thyroid Nodules
  9. Diagnostic Studies
    1. Hypothyroidism and Hyperthyroidism
    2. Thyroid Storm
    3. Myxedema Coma
    4. Thyroid Nodules
  10. Treatment
    1. Myxedema Coma
    2. Thyroid Storm
    3. Thyroid Trauma
    4. General Management of Patients With Thyroid Disease
  11. Special Circumstances
    1. Congenital Hypothyroidism
      1. Diagnosis
      2. Treatment
    2. Thyroid Disease and Pregnancy
    3. Exposure to Ionizing Radiation
    4. Pre-Existing Thyroid Disease
  12. Controversies and Cutting Edge
    1. Subclinical Hypothyroidism
      1. Subclinical Hypothyroidism in Pregnancy
    2. Thyroid Storm and Levocarnitine
    3. Thyroid Nodules
    4. Desiccated Thyroid Hormone Versus Levothyroxine
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls in the Management of Pediatric Patients With Thyroid Disease
  16. Case Conclusions
  17. Time- and Cost-Effective Strategies
  18. Clinical Pathways
    1. Clinical Pathway for the Management of Suspected Hypothyroidism
    2. Clinical Pathway for the Management of Suspected Hyperthyroidism
  19. Tables and Figures
    1. Table 1. Manifestations of Hypothyroidism and Hyperthyroidism
    2. Table 2. Causes of Acquired Hypothyroidism in Children
    3. Table 3. Causes, Pathophysiologic Features, and Frequency of Various Types of Hyperthyroidism
    4. Table 4. Dosage Information for Medications Used to Treat Thyroid Storm
    5. Figure 1. Thyroid Hormone Feedback Loops
  20. References
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Abstract

The wide range and vague nature of clinical presentations of thyroid emergencies make accurate and timely diagnosis challenging. Patients with a variety of thyroid conditions present to the emergency department, and appropriate suspicion can reduce unnecessary delay and expense in determining the correct diagnosis. This issue reviews the current evidence for presentation, evaluation, and treatment for emergencies of thyroid function and anatomy including hypothyroidism, hyperthyroidism, thyroid nodules, and thyroid trauma. Complications of thyroid dysfunction are also considered, as well as recommendations for disposition and follow-up.

 

Case Presentations

A 4-year-old boy presents to your ED, asymptomatic after suspected ingestion of 25 tablets of his grandmother’s 300-mcg levothyroxine. The ingestion occurred 90 minutes ago. You wonder: Is this amount toxic? Would serum hormone levels be helpful? What symptoms would be concerning? How should this patient be managed?

An 8-year-old boy with a history of Down syndrome is brought in by his parents because he is lethargic. He is difficult to rouse and has a history of vomiting and diarrhea for the last 4 days. His parents say this is very unusual for him, as he is usually constipated. The boy responds slowly to voice and shows signs of dehydration on examination. His mucous membranes are tacky, his capillary refill is 4 seconds, and he has cool extremities. The patient’s heart rate is 135 beats/min and his blood pressure is 100/60 mm Hg. A review of systems reveals no recent weight change, no unusual hair growth, and no temperature intolerance. In the waiting room, oral rehydration by syringe has been unsuccessful. While you suspect that dehydration is the cause of this patient's condition and begin to calculate fluid replacement, you recall that constipation can be a symptom of thyroid disease. Should you check the patient's thyroid stimulating hormone level while you start intravenous rehydration?

A 16-year-old adolescent girl is brought in by EMS for reported mania. According to her parents, she has been a good student, with no history of drug use. Her initial vital signs are: temperature, 38.9°C (102°F); heart rate, 120 beats/min; respiratory rate, 16 breaths/min; and blood pressure, 140/80 mm Hg. The patient is sweaty, pale, thrashing, and speaking rapidly and incomprehensibly. As you prepare to draw initial laboratory samples, you wonder if this could be a manifestation of hyperthyroidism, and whether drawing samples for thyroid stimulating hormone testing is appropriate. How will you manage this patient if there is evidence of thyrotoxicosis? Will it change your initial medications for treatment of the agitated patient? Are there important findings on other tests you need to watch for?

 

Introduction

Thyroid disease is a common health problem in the population at large, but it does not often present to the emergency department (ED) as a primary concern. Thyroid disease is less common in children than adults. A Scottish population-based study found the prevalence of hypothyroidism to be 0.135% among all residents aged < 22 years. Of affected patients, 73% had acquired hypothyroidism, 66% of which had an autoimmune basis.1 In areas with screening programs, patients with congenital hypothyroidism are usually identified in the neonatal period; however, this condition may present later in infancy if screening was not performed or in children with diets low in iodine.

For an emergency clinician, thyroid disease is often difficult to diagnose, not only because it is uncommon, but because the signs and symptoms are vague and nonspecific and the variety of presentations is wide. This often leads to a delay in diagnosis. Two separate chart reviews2,3 demonstrated that children who were ultimately diagnosed with hyperthyroidism underwent testing for symptoms related to behavior (eg, attention deficit-hyperactivity disorder) or cardiac symptoms, were referred for non–endocrine subspecialist assessments 22.4% of the time, and underwent diagnostic testing and procedures costing as much as $14,000 per patient before their thyroid disease was confirmed.

Nonetheless, the ED provides an ideal setting to diagnose and arrange for treatment of thyroid disease. A fresh look at symptoms and signs, the availability of diagnostic testing, and access to pediatric subspecialists for follow-up makes thyroid disease relatively simple to diagnose and treat. Because of the severity of symptoms that can develop, the ED is also the site where acute thyrotoxicosis due to endogenous or exogenous hormone is most likely to present. This issue of Pediatric Emergency Medicine Practice reviews common presentations of various thyroid diseases and provides evidence-based recommendations for the management of patients with these diseases.

 

Critical Appraisal of the Literature

A literature search for articles published from 1990 to the present was performed in PubMed using the terms child, guidelines, thyroid emergencies, hypothyroid, hyperthyroid, thyroid trauma, and thyroid nodule. In addition, the Cochrane Database of Systematic Reviews was searched for reviews related to pediatric thyroid disease.

Recent high-level evidence for most thyroid disease is difficult to find. New evidence in the last 25 years is restricted to reviews, case reports, small studies, and clinical practice guidelines based on older evidence. Recent guidelines exist for the diagnosis and management of thyroid nodules,4,5 congenital hypothyroidism,6,7 childhood hypothyroidism,8,9 hyperthyroidism,10 and Graves disease.11

 

Risk Management Pitfalls in the Management of Pediatric Patients With Thyroid Disease

6. “My patient ingested a family member's thyroid medicine. I checked his thyroid levels when he came in, and they were normal. I don't understand how he got so much worse overnight.”

Young children are at risk for thyrotoxicosis from ingestion of levothyroxine, but usually do not show symptoms at the index visit. Ensure that repeat clinical assessments and laboratory evaluations are performed in follow-up.

7. “I gave acetaminophen to my patient with thyroid storm, but she just kept getting warmer and acting sicker!”

Propranolol and external cooling are the mainstays of ED treatment for thyroid storm. Antipyretics are of uncertain benefit, and salicylates in particular are contraindicated, as they may increase free thyroid hormone levels.

8. “Last week I saw a boy with recently diagnosed attention-deficit/hyperactivity disorder. He just had behavioral complaints, so I sent him home. He came back and was diagnosed with thyroid disease!”

Strongly consider evaluating TSH levels in patients with new behavioral complaints, unexplained cardiac complaints, or slipped capital femoral epiphysis.

 

Tables and Figures

Table 1. Manifestations of Hypothyroidism and Hyperthyroidism12,76

Condition
Symptoms
Signs
Hypothyroidism
  • Cold intolerance
  • Increased sleep
  • Decreased energy
  • Muscle weakness, cramps
  • Menometrorrhagia
  • Delayed or pseudo-precocious puberty
  • Galactorrhea
  • Headache
  • Decreased growth velocity
  • Delayed osseous maturation
  • Goiter
  • Weight gain (usually due to myxedema)
  • Constipation
  • Bradycardia
  • Ataxia
  • Nerve entrapment
  • Laboratory changes (hyponatremia, macrocytic anemia, hypercholesterolemia, elevated creatine phosphokinase)
Hyperthyroidism
  • Hyperactivity, irritability, altered mood, insomnia, anxiety, poor concentration
  • Heat intolerance, increased sweating
  • Palpitations
  • Fatigue, weakness
  • Dyspnea
  • Weight loss with increased appetite (weight gain in 10% of patients)
  • Pruritus
  • Increased stool frequency
  • Thirst and polyuria
  • Oligomenorrhea or amenorrhea
  • Sinus tachycardia, atrial fibrillation (rare in children), supraventricular tachycardia
  • Fine tremor, hyperkinesis, hyperreflexia
  • Warm, moist skin
  • Palmar erythema, onycholysis
  • Hair loss or thinning
  • Osteoporosis
  • Muscle weakness and wasting
  • High-output heart failure
  • Chorea
  • Periodic (hypokalemic) paralysis (primarily in Asian men)
  • Psychosis (rare)
Signs specific for Graves disease:
  • Thyroid acropachy (rare in children)
  • Diffuse goiter
  • Localized dermopathy (rare in children)
  • Lymphoid hyperplasia
  • Ophthalmopathy
    • Eye discomfort
    • Retrobulbar pressure or pain
    • Eyelid lag or retraction
    • Periorbital edema, chemosis, scleral or conjunctival injection
    • Exophthalmos (proptosis)
    • Extraocular muscle dysfunction
    • Exposure keratitis
    • Optic neuropathy
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References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

  1. Hunter I, Greene SA, MacDonald TM, et al. Prevalence and aetiology of hypothyroidism in the young. Arch Dis Child. 2000;83(3):207-210. (Population based cohort study; 103,500 patients)
  2. Sims EK, Eugster EA, Nebesio TD. Detours on the road to diagnosis of Graves disease. Clin Pediatr (Phila). 2012;51(2):160-164. (Chart review; 76 patients)
  3. Loomba-Albrecht LA, Bremer AA, Styne DM, et al. High frequency of cardiac and behavioral complaints as presenting symptoms of hyperthyroidism in children. J Pediatr Endocrinol Metab. 2011;24(3-4):209-213. (Chart review; 76 patients)
  4. Francis GL, Waguespack SG, Bauer AJ, et al. Management guidelines for children with thyroid nodules and differentiated thyroid cancer. Thyroid. 2015;25(7):716-759. (Clinical practice guideline)
  5. Gharib H, Papini E, Paschke R, et al. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules: executive summary of recommendations. J Endocrinol Invest. 2010;33(5):287-291. (Clinical practice guideline)
  6. Leger J, Olivieri A, Donaldson M, et al. European Society for Paediatric Endocrinology consensus guidelines on screening, diagnosis, and management of congenital hypothyroidism. J Clin Endocrinol Metab. 2014;99(2):363-384. (Clinical practice guideline)
  7. Mass Screening Committee, Japanese Society for Pediatric Endocrinology, Japanese Society for Mass Screening, et al. Guidelines for mass screening of congenital hypothyroidism (2014 revision). Clin Pediatr Endocrinol. 2015;24(3):107-133. (Clinical practice guideline)
  8. Brenta G, Vaisman M, Sgarbi JA, et al. Clinical practice guidelines for the management of hypothyroidism. Arq Bras Endocrinol Metabol. 2013;57(4):265-291. (Clinical practice guideline, systematic review)
  9. Lazarus J, Brown RS, Daumerie C, et al. 2014 European thyroid association guidelines for the management of subclinical hypothyroidism in pregnancy and in children. Eur Thyroid J. 2014;3(2):76-94. (Clinical practice guideline)
  10. Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26(10):1343-1421. (Clinical practice guideline)
  11. Committee on Pharmaceutical Affairs, Japanese Society for Pediatric Endocrinology, the Pediatric Thyroid Disease Committee, et al. Guidelines for the treatment of childhood-onset Graves’ disease in Japan, 2016. Clin Pediatr Endocrinol. 2017;26(2):29-62. (Clinical practice guideline)
  12. Zhu Y, Qiu W, Deng M, et al. Myxedema coma: a case report of pediatric emergency care. Medicine (Baltimore). 2017;96(21):e6952. (Case report)
  13. Root JM, Vargas M, Garibaldi LR, et al. Pediatric patient with altered mental status and hypoxemia: case report. Pediatr Emerg Care. 2017;33(7):486-488. (Case report)
  14. Thompson MD, Henry RK. Myxedema coma secondary to central hypothyroidism: a rare but real cause of altered mental status in pediatrics. Horm Res Paediatr. 2017;87(5):350-353. (Case report)
  15. Schutt-Aine JC. Hypothyroid myxedema and hyponatremia in an eight-year-old child: a case report. J Natl Med Assoc. 1980;72(7):705-708. (Case report)
  16. Kliegman R, Behrman RE, Nelson WE. Nelson Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier; 2016. (Textbook)
  17. Majlesi N, Greller HA, McGuigan MA, et al. Thyroid storm after pediatric levothyroxine ingestion. Pediatrics. 2010;126(2):e470-e473. (Case report)
  18. Ho J, Jackson R, Johnson D. Massive levothyroxine ingestion in a pediatric patient: case report and discussion. CJEM. 2011;13(3):165-168. (Case report)
  19. Hays HL, Jolliff HA, Casavant MJ. Thyrotoxicosis after a massive levothyroxine ingestion in a 3-year-old patient. Pediatr Emerg Care. 2013;29(11):1217-1219. (Case report)
  20. Papi G, Corsello SM, Pontecorvi A. Clinical concepts on thyroid emergencies. Front Endocrinol (Lausanne). 2014;5:102. (Review article)
  21. Akamizu T, Satoh T, Isozaki O, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid. 2012;22(7):661-679. (Literature review, development of diagnostic criteria)
  22. Delikoukos S, Mantzos F. Thyroid storm induced by blunt thyroid gland trauma. Am Surg. 2007;73(12):1247-1249. (Case report)
  23. Arana-Garza S, Juarez-Parra M, Monterrubio-Rodriguez J, et al. Thyroid gland rupture after blunt neck trauma: a case report and review of the literature. Int J Surg Case Rep. 2015;12:44-47. (Case report and literature review)
  24. Araujo DB, Barone B, Melleti NF, et al. Thyroid disorders are common in first-degree relatives of individuals with type 1 diabetes mellitus. Arch Endocrinol Metab. 2015;59(2):112-115. (Cross-sectional study; 40 patients and 40 relatives)
  25. Salzano G, Lombardo F, Arrigo T, et al. Association of five autoimmune diseases in a young woman with Down’s syndrome. J Endocrinol Invest. 2010;33(3):202-203. (Case report)
  26. Marques I, Silva A, Castro S, et al. Down syndrome, insulin-dependent diabetes mellitus and hyperthyroidism: a rare association. BMJ Case Rep. 2015;2015. (Case report)
  27. Lombardo F, Messina MF, Salzano G, et al. Prevalence, presentation and clinical evolution of Graves’ disease in children and adolescents with type 1 diabetes mellitus. Horm Res Paediatr. 2011;76(4):221-225. (Case-control, 1323 cases/109 controls)
  28. Ferrari SM, Elia G, Virili C, et al. Systemic lupus erythematosus and thyroid autoimmunity. Front Endocrinol (Lausanne). 2017;8:138. (Literature review)
  29. Srinivasan R, Cosgrove M, Huddart S, et al. Autoimmune thyrotoxicosis with achalasia cardia. Indian J Pediatr. 2009;76(8):850-851. (Case report)
  30. Ioachimescu AG, Makdissi A, Lichtin A, et al. Thyroid disease in patients with idiopathic thrombocytopenia: a cohort study. Thyroid. 2007;17(11):1137-1142. (Cohort study; 98 patients)
  31. Elfstrom P, Montgomery SM, Kampe O, et al. Risk of thyroid disease in individuals with celiac disease. J Clin Endocrinol Metab. 2008;93(10):3915-3921. (Cross-sectional study; 14,021 patients in national database)
  32. Mehrdad M, Mansour-Ghanaei F, Mohammadi F, et al. Frequency of celiac disease in patients with hypothyroidism. J Thyroid Res. 2012;2012:201538. (Cohort study; 454 patients)
  33. Tuhan H, Isik S, Abaci A, et al. Celiac disease in children and adolescents with Hashimoto thyroiditis. Turk Pediatri Ars. 2016;51(2):100-105. (Cohort study; 80 patients)
  34. Koves IH, Cameron FJ, Kornberg AJ. Ocular myasthenia gravis and Graves disease in a 10-year-old child. J Child Neurol. 2009;24(5):615-617. (Case report)
  35. Cho SB, Kim JH, Cho S, et al. Vitiligo in children and adolescents: association with thyroid dysfunction. J Eur Acad Dermatol Venereol. 2011;25(1):64-67. (Case control; 254 cases/122 controls)
  36. Bull MJ, the Committee on Genetics. Health supervision for children with Down syndrome. Pediatrics. 2011;128(2):393-406. (Clinical practice guideline)
  37. Congedo V, Celi FS. Thyroid disease in patients with McCune-Albright syndrome. Pediatr Endocrinol Rev. 2007;4 Suppl 4:429-433. (Literature review)
  38. Livadas S, Xekouki P, Fouka F, et al. Prevalence of thyroid dysfunction in Turner’s syndrome: a long-term follow-up study and brief literature review. Thyroid. 2005;15(9):1061-1066. (Cohort study; 84 patients)
  39. Hatch M, Furukawa K, Brenner A, et al. Prevalence of hyperthyroidism after exposure during childhood or adolescence to radioiodines from the Chernobyl nuclear accident: dose-response results from the Ukrainian-American Cohort Study. Radiat Res. 2010;174(6):763-772. (Cohort study; 11,853 patients)
  40. Ostroumova E, Brenner A, Oliynyk V, et al. Subclinical hypothyroidism after radioiodine exposure: Ukrainian-American cohort study of thyroid cancer and other thyroid diseases after the Chernobyl accident (1998-2000). Environ Health Perspect. 2009;117(5):745-750. (Cross-sectional study; 11,853 patients)
  41. Ostroumova E, Rozhko A, Hatch M, et al. Measures of thyroid function among Belarusian children and adolescents exposed to iodine-131 from the accident at the Chernobyl nuclear plant. Environ Health Perspect. 2013;121(7):865-871. (Cross-sectional study; 10,827 patients)
  42. Tronko MD, Howe GR, Bogdanova TI, et al. A cohort study of thyroid cancer and other thyroid diseases after the Chernobyl accident: thyroid cancer in Ukraine detected during first screening. J Natl Cancer Inst. 2006;98(13):897-903. (Cross-sectional study; 32,386 patients)
  43. Cardis E, Kesminiene A, Ivanov V, et al. Risk of thyroid cancer after exposure to 131I in childhood. J Natl Cancer Inst. 2005;97(10):724-732. (Case control; 276 cases/1300 controls)
  44. Chow EJ, Friedman DL, Stovall M, et al. Risk of thyroid dysfunction and subsequent thyroid cancer among survivors of acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study. Pediatr Blood Cancer. 2009;53(3):432-437. (Case control; 3579 cases/3846 controls)
  45. Chogle A, Saps M. Yield and cost of performing screening tests for constipation in children. Can J Gastroenterol. 2013;27(12):e35-e38. (Chart review; 7472 patients)
  46. Peck DM, Voss LM, Voss TT. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2017;95(12):779-784. (Review article)
  47. Uday S, Scott B, Alvi S. Hashimoto’s hypothyroidism presenting with SUFE (slipped upper femoral epiphysis). BMJ Case Rep. 2014;2014. (Case report)
  48. Purkait R, Prasad A, Bhadra R, et al. Massive pericardial effusion as the only manifestation of primary hypothyroidism. J Cardiovasc Dis Res. 2013;4(4):248-250. (Case report)
  49. Bagnasco M, Minciullo PL, Saraceno GS, et al. Urticaria and thyroid autoimmunity. Thyroid. 2011;21(4):401-410. (Review article)
  50. Nandi-Munshi D, Tridgell A, Taplin CE. Acute ovarian torsion and primary hypothyroidism. Pediatrics. 2013;132(1):e233-e238. (Case report)
  51. Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006;35(4):663-686. (Review article)
  52. Gilbert J. Thyrotoxicosis - investigation and management. Clin Med (Lond). 2017;17(3):274-277. (Review article)
  53. Hanley P, Lord K, Bauer AJ. Thyroid disorders in children and adolescents: a review. JAMA Pediatr. 2016;170(10):1008-1019. (Literature review)
  54. Brown RS. Autoimmune thyroiditis in childhood. J Clin Res Pediatr Endocrinol. 2013;5 Suppl 1:45-49. (Literature review)
  55. Counts D, Varma SK. Hypothyroidism in children. Pediatr Rev. 2009;30(7):251-258. (Review article)
  56. Martinez-Diaz GJ, Formaker C, Hsia R. Atrial fibrillation from thyroid storm. J Emerg Med. 2012;42(1):e7-e9. (Case report)
  57. Anjo D, Maia J, Carvalho AC, et al. Thyroid storm and arrhythmic storm: a potentially fatal combination. Am J Emerg Med. 2013;31(9):1418 e1413-e1415. (Case report)
  58. Albert BB, Eckersley LG, Skinner JR, et al. QT prolongation in a child with thyroid storm. BMJ Case Rep. 2014;2014. (Case report)
  59. LaFranchi S. Myxedema coma. Clinical Advisor. 2017. Available at: http://www.clinicaladvisor.com/pediatrics/myxedema-coma/article/620175/. Accessed June 15, 2018. (Review article)
  60. Garel C, Leger J. Thyroid imaging in children. Endocr Dev. 2007;10:43-61. (Literature review)
  61. Mussa A, De Andrea M, Motta M, et al. Predictors of malignancy in children with thyroid nodules. J Pediatr. 2015;167(4):886-892. (Cohort study; 184 patients)
  62. Zenno A, Orsdemir SC, Conroy R. et al. A case of pediatric myxedema coma in the United States: a rare but possible diagnosis [Abstact SAT-052]. Endocrine Society 98th Annual Meeting and Expo. 2016. (Abstract of a case report)
  63. Satoh T, Isozaki O, Suzuki A, et al. 2016 guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition). Endocr J. 2016;63(12):1025-1064. (Clinical practice guideline)
  64. Alba P, Mitre N, Feldt M. More than one way to skin a thyroid. Managing pediatric hypothyroidism with weekly intramuscular levothyroxine. J Pediatr Endocrinol Metab. 2016;29(6):745-748. (Case series)
  65. American Academy of Pediatrics, Rose SR, Section on Endocrinology and Committee on Genetics, et al. Update of newborn screening and therapy for congenital hypothyroidism. Pediatrics. 2006;117(6):2290-2303. (Practice guideline, algorithm)
  66. Abalovich M, Amino N, Barbour LA, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2007;92(8 Suppl):S1-S47. (Clinical practice guideline based on most recent 2 decades of evidence and expert consensus)
  67. Ron E, Lubin JH, Shore RE, et al. Thyroid cancer after exposure to external radiation: a pooled analysis of seven studies. Radiat Res. 1995;141(3):259-277. (Meta-analysis; 58,000 patients and 61,000 controls)
  68. Koulouri O, Moran C, Halsall D, et al. Pitfalls in the measurement and interpretation of thyroid function tests. Best Pract Res Clin Endocrinol Metab. 2013;27(6):745-762. (Review paper)
  69. Wu T, Flowers JW, Tudiver F, et al. Subclinical thyroid disorders and cognitive performance among adolescents in the United States. BMC Pediatr. 2006;6:12. (Chart review; 398 patients)
  70. Villar HC, Saconato H, Valente O, et al. Thyroid hormone replacement for subclinical hypothyroidism. Cochrane Database Syst Rev. 2007(3):CD003419. (Systematic review; 12 trials)
  71. Benvenga S, Ruggeri RM, Russo A, et al. Usefulness of L-carnitine, a naturally occurring peripheral antagonist of thyroid hormone action, in iatrogenic hyperthyroidism: a randomized, double-blind, placebo-controlled clinical trial. J Clin Endocrinol Metab. 2001;86(8):3579-3594. (Double-blind, crossover, placebo-controlled trial; 50 patients)
  72. Benvenga S, Lapa D, Cannavo S, et al. Successive thyroid storms treated with L-carnitine and low doses of methimazole. Am J Med. 2003;115(5):417-418. (Letter to the editor and case report of 1 patient)
  73. Kimmoun A, Munagamage G, Dessalles N, et al. Unexpected awakening from comatose thyroid storm after a single intravenous injection of L-carnitine. Intensive Care Med. 2011;37(10):1716-1717. (Case report; 1 patient)
  74. Kang GY, Parks JR, Fileta B, et al. Thyroxine and triiodothyronine content in commercially available thyroid health supplements. Thyroid. 2013;23(10):1233-1237. (Analysis of 10 over-the-counter supplements for content of thyroid hormones)
  75. Hoang TD, Olsen CH, Mai VQ, et al. Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study. J Clin Endocrinol Metab. 2013;98(5):1982-1990. (Randomized clinical trial; 70 patients)
  76. Weetman, AP. Graves disease. N Eng J Med. 2000;343(17):1236-1248. (Review article)
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Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Turner, Dr. Caglar, Dr. Cantor, Dr. Claudius, Dr. Horeczko, Dr. Mishler, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Dr. Jagoda made the following disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers Inc; Consulting fees, EB Medicine.

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Last Modified: 12/18/2018
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