Case: New-onset hyperthyroidism in an adolescent girl. Is it Graves’ disease?

A 16-year-old youth presented with a month-long history of nausea and vomiting, mainly postprandial, along with significant weight loss. Other associated symptoms included fatigue, irritability, occasional palpitations, and heat intolerance. She also reported intermittent vaginal bleeding for two weeks. There was no associated hair loss, diarrhea, or tremors. The review of systems was otherwise negative. She was a previously healthy young person, receiving topical steroids and emollients for eczema, and no other medications or supplements. She had a family history of autoimmune hyperthyroidism but no other conditions. She had experienced menarche at 13 years old and had regular monthly periods up until two months before the visit. She was sexually active. She denied drug or alcohol use. She presented to our paediatric emergency department for assessment. The physical examination was described as unremarkable. Investigations revealed elevated thyroid hormone levels and suppressed thyroid-stimulating hormone (TSH). She was diagnosed with hyperthyroidism and was started on Methimazole and Atenolol. She was referred to the paediatric endocrinology clinic for further management. On review in the endocrine clinic three weeks later, examination showed a mildly enlarged thyroid gland, which was smooth, non-tender, with no associated lymphadenopathy. There were no eye changes. Abdominal palpation revealed a gravid abdomen with a fundal height at the level of the umbilicus. Investigations confirmed pregnancy with positive beta subunit of human chorionic gonadotropin (β-HCG) test. Thyroperoxidase and TSH receptor antibodies were negative. The endocrinology team went over this information with the youth. She decided to involve a trusted adult and had a follow-up visit with their family doctor. On further investigations, β-HCG levels were markedly elevated, and a pelvic ultrasound showed a large mass in the uterus with innumerable cysts. These findings were in keeping with a complete molar pregnancy. She was admitted to hospital, and dilatation and curettage (D&C) was performed. With these findings and negative thyroid autoantibodies, it became clear that the underlying cause of her thyrotoxicosis was the gestational trophoblastic disease. She was closely followed over the following months. Methimazole was gradually decreased and discontinued three months after her D&C. As her β-HCG levels decreased, her symptoms quickly improved, and her thyroid function tests normalized (Table 1). She was discharged from the endocrinology clinic after four months. Gynaecology continued to follow. Investigations β-HCG beta subunit of human chorionic gonadotropin; D&C Dilatation and curettage; TSH Thyroid-stimulating hormone. Investigations β-HCG beta subunit of human chorionic gonadotropin; D&C Dilatation and curettage; TSH Thyroid-stimulating hormone. The most common cause of thyrotoxicosis is Graves’ disease (GD). The onset of GD usually occurs during adolescence, and females are more frequently affected. However, other aetiologies, such as thyroiditis, toxic nodules, and exogenous administration of thyroid hormones are also seen in all age groups. The main differential diagnosis during pregnancy is gestational transient thyrotoxicosis, which can occur in approximately 2%–5% of pregnancies, with variable reported incidence across the literature (1). The α-subunit of HCG is identical to that of TSH and can bind and activate its receptor. Serum HCG levels correlate with the severity of the thyrotoxicosis, and patients with gestational transient thyrotoxicosis often experience hyperemesis gravidarum. Markedly elevated serum HCG levels are seen in gestational trophoblastic disease and germ cell tumours. The possibility of pregnancy should always be discussed in sexually active youth who present with different complaints. It is important that adolescents who are pregnant receive appropriate counselling and support during this time. In new-onset hyperthyroidism, pregnancy deserves attention, not only as a potential aetiology, but due to the teratogenic effect of some antithyroid drugs. Intrauterine exposure to methimazole can result in multisystem abnormalities including choanal atresia, cutis aplasia, and malformations of the gastrointestinal tract (2). All patients who are commenced on antithyroid medications ought to be informed about this risk, and alternative antithyroid medications should be used during the first trimester of pregnancy. Further, rare diagnoses such as gestational trophoblastic disease can have severe morbidity. This comprises is a group of conditions in which abnormal trophoblast cells grow inside the uterus, and should be suspected when patients present with an abnormally enlarged uterus for the gestational age, very high β-HCG levels, and vaginal bleeding. Gestational trophoblastic disease range from benign conditions, such as molar pregnancies, to malignant forms like choriocarcinoma. Careful monitoring and treatment and monitoring are therefore warranted. This case outlines the importance of a thorough history and physical examination, which are essential in making accurate diagnoses and guiding appropriate management for any condition. A holistic approach, even in subspecialty settings, is undoubtedly needed to provide youth-centred care. Elevated HCG can result in hyperthyroidism, due to cross-reactivity with TSH receptors. In adolescents with the potential for pregnancy, this should be always considered as a possibility and discussed. This is particularly important before the commencement of antithyroid and other teratogenic medications. A thorough history and physical examination are essential in making accurate diagnoses and guiding appropriate management. The patient and her parents provided consent for the publication of this report for educational purposes. None declared.

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