Radioiodine Uptake in the Study of Different Types of Hypothyroidism in Childhood

S OF ILLUSTRATIVE HISTORIES Patients with Marked Symptoms of Cretinism From Birth and No Uptake of V31 Case 1. It was noted at birth that the infant had a peculiar bloated appearance with puffy features. short fat neck and depressed nasal bridge. The tongue was thick and protruded so that he had difficulty breathing and feeding. His hands and feet were always cold and the skin was dry. dusky and by guest on August 16, 2017 Downloaded from 296 SAMUEL H. SILVERMAN AND LAWSON WILKINS mottled. The bowels were always constipated. When examined at 2 mo., he presented a typical cretinoid appearance. The epiphysial development was less than normal for a newborn infant and there was characteristic dysgenesis of the cuboid of the foot. Case 7. From the time of birth, the child was inactive, and his skin was dusky, mottled and cold. He was chronically constipated. An umbilical hernia was present. He took his feedings poorly and grew and gained very little. He took little interest in his environment. The first tooth erupted at 21 mo., and he was unable to sit alone at 2 yr. When first examined at 2 yr., he presented a characteristic cretinoid appearance. The height age was 5 mo. His osseous development had not progressed beyond the birth level and there was dysgenesis of the epiphyses at the knee. Patients with Insidious Onset of Symptoms of Hypothyroidism During Early Months and Slight Uptake of I’s’ Case 10. This boy was slow in his growth and development. He sat alone at 14 mo., cut his first first tooth at 17 mo. and began to walk at 23 mo. At 20 mo., his osseous development was that of a newborn infant. However, he had always been fairly alert and active, and numerous photographs showed that he did not have a cretinoid facies and was not puffy or myxedematous. Thyroid treatment with doses of #{188} to 1/2 gr. daily was given at 2 1 mo. for a few weeks, but it was discontinued 2 mo. prior to the I’s’ study. The serum cholesterol was 448 mg./100 cc. Case 11. This child was considered normal and showed nothing unusual in the character of her features, skin or color until she was about 1 yr. of age. However, no teeth erupted until she was I 3 mo. After she was 1 yr. of age, she became progressively more apathetic and ceased to grow or develop. A second tooth erupted at 15 mo. but no more appeared until the 21st mo. At the age of 21 mo. her height age was 10 mo., bone age 6 mo. Her features were not coarse or cretinoid. Thyroid therapy was begun at this time and caused marked clinical response with accelerated growth and development. The V i study made when she was 81/4 yr. old showed a moderate uptake in spite of the fact that she had been receiving thyroid 1#{189} gr. daily for the past 6#{189}yr. Case 12. The patient seemed normal at birth. At 3 mo. it was noted that the skin had a yellowish tinge. She sat alone at 7 mo. and walked at 18 mo., but she was relatively inactive and tired easily. The first teeth erupted at 14 mo. At 2 yr. she became chronically constipated. After 3 yr. the mother noticed that she was growing very little. When examined at 4 yr., 10 mo., she did not have characteristic cretinoid features but had an infantile type of naso-orbital development. Her height age was 3 yr. The osseous development showed scattering between the levels of 9 mo. and 3 yr. with an average development of 9 to 12 mo. All the postnatal centers including the head of the humerus (3 mo.) and the head of the femur (9 mo.) showed dysgenesis. Patients with Onset of Hypothyroidism in Early Months Who Had Normal or Enlarged Thyroid Glands and Showed Normal Uptake of I” Case 13. This boy had been slow in his growth and development. The first tooth had erupted at 13 mo.; he sat alone at 13 mo. and walked at 18 mo. He had had a poor appetit#{231} but was not constipated. His features had never become puffy or cretinoid. When he was examined elsewhere at 1 1 mo. his height age was 5 mo. and no postnatal centers had ossified. From 1 1 to 34 mo. he was treated daily with #{189} gr. of desiccated thyroid or less. When he was studied at 2 yr., I I mo., his height age was 2 yr. and his bone age was 9 mo. At that time thyroid had been omitted for 10 days, and there were circulatory changes and coolness of the skin suggestive of hypothyroidism but there was no myxedema. The serum cholesterol was 420%. A number of examiners thought that his thyroid gland was of normal size and consistency. Certainly no goiter was visible or demonstrable on roentgenographic examination of the mediastinum. Following the demonstration of a normal uptake of V’1 he was allowed to continue without thyroid therapy for another 7 wk. in order to establish the diagnosis more conclusively. at the end of which the cholesterol had risen to 460 mg./100 cc. Case 14. There was no history of any thyroid disturbance in the family and the patient had 2 normal siblings. She had always lived in Baltimore and had taken a normal diet. She seemed normal at birth but during the 1st 2 wk. of life had a severe attack of epidemic diarrhea of the newborn infant with jaundice. The first teeth did not erupt until she was 15 mo. old, and she did not walk until the age of 2 yr. She grew slowly. She was relatively inactive and phlegmatic and was by guest on August 16, 2017 Downloaded from RADIOIODINE UPTAKE IN HYPOTHYROIDISM 297 constipated. Her color was always pale and slightly yellowish. When she was 6 yr. old an enlargement of the thyroid was noticed for the first time. When she was examined at the age of 61/4 yr., her height age was 3 yr. and her bone age 13/4 yr. There was dysgenesis of the heads of the femora and humeri. Her skin was pale and cool and the musculature flabby. There were no signs of myxedema. The serum cholesterol was 420 mg./100 cc. The thyroid gland was diffusely enlarged and firm, about I #{189} times the normal size, but it was apparent only when she tilted back her head. After diagnostic studies were completed an excellent therapeutic response to desiccated thyroid confirmed the original impression of hypothyroidism. Patient with Acquired Hypothyroidism of 1 #{189} Years Duration Who Showed No Uptake of 1331 Before TSH and Normal Uptake After Its Administration Case 15. The child had grown and developed normally and had been active, energetic and alert with regular bowels and good color up until the age of 4 yr. At that time her appetite became poor and she stopped gaining. She became sluggish and apathetic. Her color became pasty ; the skin cold and dry; the bowels constipated. When she was examined at the age of 5#{189} yr., her height age was 4 yr., bone age 3#{189}yr., mental age 5 10/12 yr. She was placid and inactive. The skin was cool and pale with circulatory mottling. She was slender and showed no puffiness or myxedema. The serum cholesterol ranged between 618 and 467 mg./100 cc. ; the B.M.R. was -28%. V studies were made before starting treatment. Subsequently thyroid therapy has resulted in entirely normal growth and development. Patient with Acquired Hypothyroidism of 4 to 5 Years Duration Who Had No Uptake of I#{176} Before or After TSH Case 18. This boy had been entirely normal and was lively and energetic until he was 5 yr. of age. The first dentition, walking and talking had occurred at the average time. He had had good color and regular bowels. Linear growth had been normal until 5 yr. after which it gradually slowed, although his short height did not attract attention until he was 9 yr. After 5 yr. he gradu. ally became less energetic and was constipated. His color became pale and his skin dry and cool. None of the deciduous teeth were lost until he was 10 yr. old. Because of his pallor he was treated for anemia between the ages of 9 and 1 1 yr. When he was examined at 1 1 #{188} yr. he was slow and apathetic. His skin was cold, pale, slightly yellowish. The tissues were loose and flabby although there was no obvious myxedema. The height age was 63/4 yr., the bone age 6#{189}yr. with suggestions of epiphysial dysgenesis in some of the 4 yr. centers, but not in the earlier ones.