Alert Progression to myxedema coma is usually gradual but when stress (such as hip fracture, infection, or myocardial infarction) aggravates severe or prolonged hypothyroidism, coma may develop abruptly. Clinical effects include progressive stupor, hypoventilation, hypoglycemia, hyponatremia, hypotension, and hypothermia.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Hypothyroidism in children:
Signs and symptoms
(Professional Guide to Diseases (Eighth Edition))
The weight and length of an infant with infantile cretinism appear normal at birth, but characteristic signs of hypothyroidism develop by the time he’s 3 to 6 months old. In a breast-fed infant the onset of most symptoms may be delayed until weaning because breast milk contains small amounts of thyroid hormone.
Typically, an infant with cretinism sleeps excessively, seldom cries (except for occasional hoarse crying), and is inactive. Because of this, his parents may describe him as a “good baby — no trouble at all.” However, such behavior actually results from lowered metabolism and progressive mental impairment. The infant with cretinism also exhibits abnormal deep tendon reflexes, hypotonic abdominal muscles, a protruding abdomen, and slow, awkward movements. He has feeding difficulties, develops constipation and, because his immature liver can’t conjugate bilirubin, becomes jaundiced.
His large, protruding tongue obstructs respiration, making breathing loud and noisy and forcing him to open his mouth to breathe. He may have dyspnea on exertion, anemia, abnormal facial features — such as a short forehead; puffy, wide-set eyes (periorbital edema); wrinkled eyelids; and a broad, short, upturned nose — and a dull expression, resulting from mental retardation. His skin is cold and mottled because of poor circulation, and his hair is dry, brittle, and dull. Teeth erupt late and tend to decay early; body temperature is below normal; and pulse rate is slow.
In the child who acquires hypothyroidism after age 2, appropriate treatment can prevent mental retardation. However, growth retardation becomes apparent in short stature (due to delayed epiphyseal maturation, particularly in the legs), obesity, and a head that appears abnormally large because the arms and legs are stunted. An older child may show delayed or accelerated sexual development.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Hypothyroidism in adults:
Signs and symptoms
(Handbook of Diseases)
Typically, the early clinical features of hypothyroidism are vague and may include fatigue, forgetfulness, sensitivity to cold, unexplained weight gain, and constipation. As the disorder progresses, characteristic myxedematous signs and symptoms appear, such as decreasing mental stability; dry, flaky, inelastic skin; puffy face, hands, and feet; hoarseness; periorbital edema; upper eyelid droop; dry, sparse hair; and thick, brittle nails.
Cardiovascular involvement leads to decreased cardiac output, slow pulse rate, signs of poor peripheral circulation and, occasionally, an enlarged heart. Other common effects include anorexia, abdominal distention, menorrhagia, decreased libido, infertility, ataxia, and nystagmus. Reflexes show delayed relaxation time (especially in the Achilles tendon).
Progression to myxedema coma is usually gradual, but when stress aggravates severe or prolonged hypothyroidism, coma may develop abruptly. Clinical effects include progressive stupor, hypoventilation, hypoglycemia, hyponatremia, hypotension, and hypothermia.
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Source: Handbook of Diseases, 2003
Hypothyroidism in children:
Signs and symptoms
(Handbook of Diseases)
The weight and length of an infant with infantile cretinism appear normal at birth, but characteristic signs of hypothyroidism develop by the time he’s 3 to 6 months old. In a breast-fed infant, onset of most symptoms may be delayed until weaning because breast milk contains small amounts of thyroid hormone.
Typically, an infant with cretinism sleeps excessively, seldom cries (except for occasional hoarse crying), and is inactive. Because of this, his parents may describe him as a “good baby — no trouble at all.” Such behavior actually results from lowered metabolism and progressive mental impairment. The infant with cretinism also exhibits abnormal deep tendon reflexes, hypotonic abdominal muscles, a protruding abdomen, and slow, awkward movements. He has feeding difficulties, develops constipation and, because his immature liver can’t conjugate bilirubin, becomes jaundiced.
His large, protruding tongue obstructs respiration, making breathing loud and noisy and forcing him to open his mouth to breathe. He may have dyspnea on exertion; anemia; abnormal facial features such as a short forehead; puffy, wide-set eyes (periorbital edema); wrinkled eyelids; and a broad, short, upturned nose — and a dull expression, resulting from mental retardation. His skin is cold and mottled because of poor circulation, and his hair is dry, brittle, and dull. Teeth erupt late and tend to decay early, body temperature is below normal, and pulse rate is slow.
In the child who acquires hypothyroidism after age 2, appropriate treatment can prevent mental retardation. However, growth retardation becomes apparent in short stature (due to delayed epiphyseal maturation, particularly in the legs), obesity, and a head that appears abnormally large because the arms and legs are stunted. An older child may show delayed or accelerated sexual development.
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Source: Handbook of Diseases, 2003
Decreased Activity Level - Case 2-1: 15-Year-Old Girl:
IV. Clinical Presentation
(Pediatric Complaints and Diagnostic Dilemmas)
Vitamin B12 plays an important role as a cofactor for two metabolic reactions: methylation
of homocysteine to methionine and conversion of methylmalonyl coenzyme A (CoA)
to succinyl CoA. Vitamin B
12 deficiency leads to accumulation of these precursors. Methionine is an
important step in the synthesis of DNA. In individuals with vitamin B
12 deficiency, RNA and cytoplasmic components are produced normally, and red blood
cell (RBC) production in the bone marrow yields large cells and, hence, a
macrocytic anemia. Methionine is also converted to S-adenosylmethionine, which
is used in methylation reactions in the CNS; therefore, CNS effects are seen
with vitamin B
12 deficiency. Neurologic manifestations in children include abnormalities such as
paresthesias, loss of developmental milestones, hypotonia, seizures, dementia,
and depression. The neurologic changes are not always reversible.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Decreased Activity Level - Case 2-2: 2-Week-Old Boy:
IV. Clinical Presentation
(Pediatric Complaints and Diagnostic Dilemmas)
There are several clinical forms of presentation for CAH. Androgen excess
results in virilization. In the female, there is usually some degree of
clitoromegaly and labial fusion, but the female internal genital organs are
normal. Mineralocorticoid deficiency results in an inability to exchange
potassium for sodium in the distal tubule of the nephron; hence, there is
sodium loss in the urine and an inability to secrete potassium. This
electrolyte abnormality is referred to as salt wasting. Patients with the
salt-wasting type of CAH become symptomatic shortly after birth. They have
progressive weight loss, dehydration, and vomiting. If the condition is not
recognized, death occurs within a few weeks.
Girls with virilization tend to be diagnosed at birth due to their ambiguous
genitalia. Boys may be diagnosed at 1 to 2 weeks of life if they present with a
salt-wasting type of CAH or at about 4 years of age if they present with
premature development of secondary sexual characteristics.
The two most common forms of CAH, 21-hydroxylase deficiency and 11-β-hydroxylase deficiency, result in virilization. Approximately 75% of the
21-hydroxylase deficiencies also cause salt wasting; however, 25% of patients
present with virilization alone. Patients with 11-
β-hydroxylase deficiency do not have salt wasting, but they develop hypertension
after the first few years of life.
The 3-β-hydroxysteroid dehydrogenase defect causes salt wasting and mild virilization.
Patients with the cholesterol side chain cleavage enzyme defect present with
salt wasting and female phenotype.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Decreased Activity Level - Case 2-3: 3-Month-Old Girl:
IV. Clinical Presentation
(Pediatric Complaints and Diagnostic Dilemmas)
The average age at onset is 10 weeks, with a range of 10 days to 7 months.
Patients typically present to medical attention with constipation, poor
feeding, irritability, and weakness. Approximately 1 week after the onset of
symptoms, additional neurologic symptoms are seen, such as facial diplegia,
weak suck, poor gag, and hypotonia. On physical examination, patients have
progressive weakness, as manifested by ptosis, poor head control, and
diminished suck, gag, and respiratory effort. The paralysis progresses in a
descending fashion. Seventy percent of patients with infantile botulism have
respiratory failure that necessitates mechanical ventilation. Patients also
have autonomic dysfunction, manifested by decreased intestinal motility,
distended urinary bladder, decreased tear production, decreased saliva
production, periodic flushing and sweating, and fluctuations in heart rate and
blood pressure. Reflexes are diminished. Other complications include syndrome
of inappropriate secretion of antidiuretic hormone (SIADH) and urinary tract
infections.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Decreased Activity Level - Case 2-4: 11-Month-Old Boy:
IV. Clinical Presentation
(Pediatric Complaints and Diagnostic Dilemmas)
The disease caused by N. meningitidis varies from asymptomatic transient bacteremia to fulminant sepsis and death.
Pathogenic
N. meningitidis colonizes the respiratory tract and may invade the bloodstream. The patient
becomes bacteremic and progressively sicker. The bacteremia may seed the
meninges, causing meningitis. Those patients who present with meningitis have a
better prognosis than do patients with bacteremia alone. Shortly after the
administration of appropriate antibiotics, some patients have a marked clinical
deterioration, ranging from hypotension to death. This deterioration is thought
to be caused by stimulation of the host inflammatory pathway by endotoxin (a
component of the gram-negative bacterial cell wall). Meningococcal disease can
lead to death in as few as 12 hours. Invasive infection usually results in
meningococcemia, meningitis, or both. However, the bacteria can infect any
organ, including myocardium, adrenals, lungs, and joint spaces. Approximately
55% of patients with meningococcal disease have meningitis. Additionally, 50%
of patients have positive blood cultures.
A history of a preceding upper respiratory tract infection can often be elicited
from patients with meningococcemia. The onset of illness is abrupt, with fever,
lethargy, and rash. The rash is typically petechial and occasionally urticarial
or maculopapular. Some patients develop fulminant meningococcemia, with
disseminated intravascular coagulopathy, shock, and myocardial dysfunction.
Coagulopathy leads to the development of purpura. There is a 20% mortality rate
in cases of fulminant disease.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Decreased Activity Level - Case 2-5: 9-Year-Old Boy:
IV. Clinical Presentation
(Pediatric Complaints and Diagnostic Dilemmas)
Hemorrhage is the initial manifestation in up to 80% of cases of cerebral AVMs.
Seizures, which occur in about one third of the cases, may result from an acute
hemorrhage or from an epileptogenic focus from a previous hemorrhage. Infants
may present with congestive heart failure and hydrocephalus. Stroke and
seizures are more commonly seen in older children. Intracranial hemorrhage may
occur after an episode of trivial head trauma. Headache is a frequent symptom
in patients with AVMs, although it is not a very specific clinical sign.
Patients with untreated AVM who have had previous hemorrhages are at a higher
risk for rebleeding. The presentation varies with the location of the AVM:
superficial AVMs cause seizures more frequently, and deep AVMs tend to manifest
with hemorrhage.
AVMs usually continue to increase in size, with increasing risk of hemorrhage
and ischemia, resulting in seizures, gliosis, and neurologic deficits. However,
some AVMs remain the same size, and some even regress.
Two thirds of adults with AVMs have documented learning disorders. The
implication is that there are functional brain deficits that may arise before
other signs and symptoms that ultimately lead to the diagnosis of a cerebral
AVM.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Decreased Activity Level - Case 2-6: 20-Month-Old Boy:
IV. Clinical Presentation
(Pediatric Complaints and Diagnostic Dilemmas)
The presentation of child abuse varies according to the type of injury
inflicted, and medical personnel should be alert to any sign that may indicate
abuse. The child may have been the victim of a one-time abuse or of multiple
previous episodes of abuse. The abuse may be physical, sexual, emotional, or
neglect. The child may have marks and bruises on the body from the abuse, there
may be a change in mental status, the child may present with an intracranial
hemorrhage, the child may present in full arrest or there may be no obvious
signs that the abuse occurred. The perpetrator may not have intended to harm
the child but may have overdisciplined or punished the child, resulting in
abuse. Physical abuse represents 25% of the cases of abuse in the United
States.
Risk factors that place a child at increased risk for abuse include
parental/caretaker factors, child factors, and situational factors. Caretaker
factors that increase the risk of abuse include caretakers who are not prepared
to perform their role, have unrealistic expectations of the child, have a poor
role model, use corporal punishment, have inconsistent discipline skills, have
an unsupportive partner, have psychological issues such as impulse disorder or
depression, have been victims of abuse themselves, or have a substance abuse
problem. Children who are handicapped, have developmental delays, or have
behavioral problems are at increased risk. Economic difficulties, poor housing,
crowding, illness, and unemployment are situations that increase the likelihood
of abuse. Injuries that have occurred without any history, inconsistent
histories,
“magical” injuries, and a delay in seeking care after injury are concerning for abuse.
Physical examination findings of patterned marks, pathognomonic injuries,
multiple injuries, injuries at various stages of healing, and unexplained
injuries are concerning for abuse.
It is important to be able to determine what constitutes abuse and what does
not. Being able to differentiate osteogenesis imperfecta from fractures due to
child abuse, Mongolian spots from bruising, and ecthyma from cigarette burns
are important skills that health care professionals should learn. Normal
bruising is common in children older than 1 year of age; it typically occurs on
the lower extremities and is not associated with petechiae, purpura, or mucosal
bleeding. It is difficult to determine which injuries were sustained
accidentally and which were caused by nonaccidental trauma. If doubt exists, a
social services report should be filed.
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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Acquired Hypothyroidism:
Acquired Hypothyroidism - signs & symptoms
(The 5-Minute Pediatric Consult)
- Early primary hypothyroidism can be asymptomatic.
- Hypothyroid-related symptoms indicate progression from compensated to uncompensated hypothyroidism.
- Hypothyroidism may be preceded in some cases by temporary hyperthyroidism (Hashitoxicosis).
- Goiter may be the presenting sign of acquired hypothyroidism; tenderness suggests an infectious process.
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Source: The 5-Minute Pediatric Consult, 2008
Article Excerpts About Symptoms of Hypothyroidism:
Symptoms may include feeling
sluggish, cold, depressed, forgetful, experiencing dry hair and skin,
constipation, and increased menstrual flow. (Source: excerpt from Thyroid Disease: NWHIC)
Hypothyroidism as a Cause of Symptoms or Medical Conditions
When considering symptoms of Hypothyroidism, it is also important to consider Hypothyroidism as a possible cause of other medical conditions.
The Disease Database lists the following medical conditions that Hypothyroidism may cause:
- (Source - Diseases Database)
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