
Case history
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.
Early history
Hover to viewEarly history
- Born at term in the UK
- Family are from Bangladesh
Presenting complaint
Hover to viewPresenting complaint
- Coughing a lot – nothing is helping
- Feeling tired
- Not vomiting when coughing, no haematemesis
- Not eating or drinking well
- No pyrexia
- No concerns with bowels or passing urine
Health and medication history
Hover to viewHealth and medication history
- No medical history, never been in hospital
- Not on any prescribed medication
- Using over-the-counter cough mixture, although it has not helped
- No herbal medication, no medication sourced from the internet, no access to recreational drugs
- Immunisations up to date – including BCG (offered in the UK in high-risk areas)
- Had chickenpox last year
- Family live in East London, known as a high-risk area with increased prevalence of tuberculosis
- No recent foreign travel, although paternal uncle has just returned from Bangladesh
Family and school history
Hover to viewFamily and school history
- Reception year at primary school
- Doing well
- Has lots of friends
- Mother has type 2 diabetes
- Maternal grandmother has an underactive thyroid
- Mother is 153 cm
- Father is 169 cm
On Examination
Temperature | 36.8°C |
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.
Testing
Investigation and rationale | Result | ||||||||||||||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Chest X-ray To look for evidence of tuberculosis: consolidation in upper lobes of the lung, because of history of cough |
Clear | ||||||||||||||||||||||||||||||
Electrocardiogram 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
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Mantoux Tuberculin skin test for identifying M. tuberculosis infection |
Negative |
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 |
Thyroid ultrasound 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) |
Results
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
How can raised levels of TSH receptor antibodies manifest clinically? What else do increased thyroid hormones do?
Hover to view our thoughtsIncreased levels can stimulate alpha and beta adrenergic receptors in the nervous system. This leads to increased catecholamine release, which results in tachycardia and sweating. Excess thyroid hormones influence epiphyseal maturation, therefore resulting in advanced growth.
Conclusion
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.