.
RETURN TO CASE OF THE MONTH INDEX
CASE-OF-THE-MONTH (January 2008)
Presented by -
(Thyroid Study Unit, Endocrine Division, Dept. Medicine,
Univ. Sao Paulo Medical School)
Juvenile hypothyroidism
MRT, 14 years old female adolescent, came to first consultation for mild obesity (BMI 27.1 kg/m˛) and stunted growth. The mother reported that the girl was healthy at birth, after a normal full-term pregnancy, with weight of 3650 g and height of 49 cm. The neonate had an APGAR of 9 without any abnormalities. The Neonatal Screening Test performed at the 7th day indicated a dried blood spot TSH value of 18.1mU/L which was below the recall value at the time (>20mU/L). The neonate had a prolonged episode of neonatal icterus and an umbilical hernia. The little girl was breast-fed for 6-7 months with normal somatic development. Apparently neuro-psycho-motor development was also normal with timely surge of teeth, speaking words, and walking alone. Later the mother noted that the child was growing behind the other girls in her school class. Furthermore the girl had school problems with repeated failures in regular tests and progressed slowly through elementary school. There was a “speech” problem (not very well described) and poor understanding of whatever she learned. At 12-13 years age puberty started with normal thelarche and pubarche, but until the first consultation she had not had menarche. She denied galactorrhea. The mother confirmed that her appetite was basically normal and she did not have an abnormal eating pattern. In spite of that the girl is constantly gaining weight. The parents are not consanguineous and there is no familial prevalence of diabetes, obesity, or thyroid disease.
An obese adolescent girl with height 135 cm (-2SD) weight of 67 kg and BMI of 27.1kg/m˛. (Figure 1) The pulse rate was 62 bpm and BP of 105 X 72 mmHg. Obesity was typically android with a waist of 92 cm. Measurements indicated a lower inferior segment (pubis–floor of 60 cm) as compared to the upper segment (cranial-pubes of 75 cm). The ratio superior / inferior was 1.25. Breasts were considered Tanner II, pubic hair Tanner III and external genitalia normal for gender and age. The thyroid gland was not visible or palpable. Liver was enlarged as felt by palpation. The skin was a dry and hyperkeratosis was present in both upper arms. Palms of the hands were yellowish. Neurological examination indicated normal hearing, some difficulties in speech and quite slow tendon reflexes.
|
|
| Figure 1. The patient appearance at first consultation. Note the low height (135 cm) and lower inferior (pubis-floor) segment. Central obesity is also observed. |