A 4-year-old girl, referred to the Paediatric Assessment Unit by the GP, with a 2-week history of a cough, feeling unwell, and tired. Accompanied by her mother.
Read the patient information below and answer Question 1.
|Heart rate||120 bpm|
|Respiratory rate||20 per min|
|O2 saturations in air||98%|
|Blood pressure on right arm||90/60 mmHg|
|Capillary refill time (CRT)||Less than 2 seconds|
|Height||112 cm (75th centile)|
|Weight||17 kg (10th centile)|
- Her ears, nose and throat are clear, but she is clammy and sweaty.
- There is no increased work of breathing, with good air entry, but there is a slight wheeze bilaterally and she has swollen cervical lymph nodes.
- She has no dysmorphic features, no goitre and is cardiovascularly stable but is tachycardic.
- She is tall for her age in comparison to her parents.
Concluding the history
Mother concerned about the cough.
Thinks she has a cold.
On asking if there was anything else, mother feels she may have been a bit more sweaty in the last few weeks, but was not concerned.
What would your differential diagnoses be?
- Upper respiratory tract infection
Which clinical signs or symptoms are making you suspicious?
- History of cough
- Tall stature
- Low weight
- Family foreign travel
- Geographical area
- Doing well at school
- Family history of thyroid disease
- Tuberculosis risk
- Family recent foreign travel
- Chickenpox history
Which laboratory tests and investigations do you are think are needed to reach your definitive diagnosis?
- Sputum sample
- Naso-pharyngeal aspirate
- Lung spirometry
- Stool sample
- Urine sample
- Blood cultures
- Chest X-ray
- ECG (electrocardiogram)
- Full blood count (FBC)
- C-reactive protein (CRP)
- Urea & electrolytes (U&E)
- Liver function tests (LFT)
- ESR (erythrocyte sedimentation rate)
- 24 hr urine collection for catecholamines
- Thyroid function tests
- Thyroid ultrasound
- Mantoux test
Chest X-ray. ECG (electrocardiogram). Full blood count (FBC). C-reactive protein (CRP). Urea & electrolytes (U&E). Liver function tests (LFT). ESR (erythrocyte sedimentation rate). 24 hr urine collection for catecholamines. Thyroid function tests. Thyroid ultrasound. Mantoux test
|Investigation and rationale||Result|
To look for evidence of tuberculosis: consolidation in upper lobes of the lung, because of history of cough
To explore cause for tachycardia, and signs of electrical activity in the heart
|Normal, with slight tachycardia|
|Bloods: FBC, U&E, LFT, CRP, ESR
To rule out signs of infection, anaemia, renal disease, liver disease, and raised ESR as seen in endocarditis
|All within normal limits
Tuberculin skin test for identifying M. tuberculosis infection
Further endocrine investigations
|Investigation and rationale||Result|
|Thyroid function tests
To look for abnormal levels of thyroid hormones
|Abnormal thyroid function test results
Free T4 26.7 pmol/L 10.5-24.5
To look for diffuse thyroid enlargement
|Enlarged thyroid, but no focal nodules|
|Urinary collection for catecholamines
To rule out excess catecholamine release from a pharchromocytoma
|Within normal limits (Priesemann et al. 2006)|
Which further blood test could be performed to further refine the diagnosis?
- Thyrotrophin-releasing hormone (TRH) test
- Combined insulin tolerance/TRH/gonadotrophin-releasing hormone test
- Thyroid-stimulating hormone (TSH) receptor antibodies
TSH receptor antibodies 0.84 miU/L (normal range 0.0–0.4)
Consistent with Graves’ disease
Management and follow-up
Referral made to the paediatric endocrinology services for management
What is your management plan and in what order would you do this?
- Commence antithyroid drug, carbimazole
- Refer to nurse-led paediatric endocrine clinic
- Refer for radioactive Iodine therapy
- Refer to surgical team for thyroidectomy
Shared care was planned with the patient’s GP, for them to repeat prescriptions of carbimazole, 5 mg once daily. A further outpatient appointment was offered for 2 weeks’ time with repeat thyroid function test. Parental understanding needed to be ensured, so a referral was made to the nurse-led thyroid clinic for further education and support.
No treatment was needed for the cough, which self-resolved.
This case shows that thyroid symptoms can be subtle and easily missed. It underlines the importance of detailed history-taking and clinical examination, and shows that sometimes the presenting complaint can be misleading.
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