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Cifras de referencia en exmenes de laboratorio en nios The Harriet Lane Handbook. 17 ed. 2005

Contents:
o o o o

I.. REFERENCE VALUES 1 II.. EVALUATION OF BODY FLUIDS 11 III.. CONVERSION FORMULAS 14 THYROID TESTS 14

Chapter 25 Blood Chemistries and Body Fluids Jason Robertson, MD These values are compiled from the published literature[1][2][3][4][5][6] and from the Johns Hopkins Hospital Department of Laboratory Medicine. Normal values vary with the analytic method used. Consult your laboratory for its analytic method and range of normal values and for less commonly used parameters, which are beyond the scope of this text. Additional normal laboratory values may be found in the Chapters 9 , 13 , and 14 . I. REFERENCE VALUES ( Table 251 ) Table 25-1 -- REFERENCE VALUES[1][2][3][4][5][6] Conventional Units ACID PHOSPHATASE (Major sources: prostate and erythrocytes) Newborn 213 yr Adult male Adult female ALANINE AMINOTRANSFERASE (ALT) (Major sources: liver, skeletal muscle, and myocardium) Neonate/infant Adult male Adult female ALBUMIN 1345 U/L 1040 U/L 735 U/L 1345 U/L 1040 U/L 735 U/L 7.419.4 U/L 6.415.2 U/L 0.511.0 U/L 0.29.5 U/L 7.419.4 U/L 6.415.2 U/L 0.511.0 U/L 0.29.5 U/L

Sl Units

Conventional Units (See Proteins) ALDOLASE (Major sources: skeletal muscle and myocardium) 1024 mo 216 yr Adult ALKALINE PHOSPHATASE (Major sources: liver, bone, intestinal mucosa, placenta, and kidney) Infant 210 yr Adolescent males Adolescent females Adult 150420 U/L 100320 U/L 100390 U/L 100320 U/L 30120 U/L 3.411.8 U/L 1.28.8 U/L 1.74.9 U/L

Sl Units

3.411.8 U/L 1.28.8 U/L 1.74.9 U/L

150420 U/L 100320 U/L 100390 U/L 100320 U/L 30120 U/L

AMMONIA (Heparinized venous specimen on ice analyzed within 30 min) Newborn 02 wk >1 mo Adult 90150 g/dL 79129 g/dL 2970 g/dL 050 g/dL 64107 mol/L 5692 mol/L 2150 mol/L 035.7 mol/L

AMYLASE (Major sources: pancreas, salivary glands, and ovaries) Newborn Adult ANTINUCLEAR ANTIBODY (ANA) Not significant Likely significant Patterns with clinical correlation: CentromereCREST NucleolarScleroderma HomogeneousSLE ANTISTREPTOLYSIN O TITER (4-fold rise in paired serial specimens is significant) Preschool School age Older adult <1 : 85 <1 : 170 <1 : 85 565 U/L 27131 U/L <1 : 80 >1 : 320 565 U/L 27131 U/L

Conventional Units Note: Alternatively, values up to 200 Todd units are normal. ASPARTATE AMINOTRANSFERASE (AST) (Major sources: liver, skeletal muscle, kidney, myocardium, and erythrocytes) Newborn Infant 13 yr 46 yr 79 yr 1011 yr 1219 yr BICARBONATE Newborn 2 mo2 yr >2 yr BILIRUBIN (TOTAL) Cord Preterm Term 01 days Preterm Term 12 days Preterm Term 35 days Preterm Term Older infant Preterm Term Adult BILIRUBIN (CONJUGATED) Neonate Infants/children BLOOD GAS, ARTERIAL
[7]

Sl Units

2575 U/L 1560 U/L 2060 U/L 1550 U/L 1540 U/L 1060 U/L 1545 U/L 1724 mEq/L 1624 mEq/L 2226 mEq/L

2575 U/L 1560 U/L 2060 U/L 1550 U/L 1540 U/L 1060 U/L 1545 U/L 1724 mmol/L 1624 mmol/L 2226 mmol/L

<2 mg/dL <2 mg/dL <8 mg/dL <8.7 mg/dL <12 mg/dL <11.5 mg/dL <16 mg/dL <12 mg/dL <2 mg/dL <1.2 mg/dL 0.31.2 mg/dL <0.6 mg/dL <0.2 mg/dL

<34 mol/L <34 mol/L <137 mol/L <149 mol/L <205 mol/L <197 mol/L <274 mol/L <205 mol/L <34 mol/L <21 mol/L 521 mol/L <10 mol/L <3.4 mol/L

Conventional Units Newborn (birth) Newborn (>24 hr) Infant (124 mo) Child (719 yr) Adult (>19 yr) PH 7.267.29 7.37 7.40 7.39 7.357.45 Pao2(mmHg) 60 70 90 96 90110 Paco2(mmHg) 55 33 34 37 3545

Sl Units HCO3-(mEq/L) 19 20 20 22 2226

Note: Venous blood gases can be used to assess acid-base status, not oxygenation. Pco2 averages 68 mmHg higher than Paco2, and pH is slightly lower. Peripheral venous samples are strongly affected by the local circulatory and metabolic environment. Capillary blood gases correlate best with arterial pH and moderately well with Paco2. Conventional Units CALCIUM (TOTAL) Preterm Full term <10 days 10 days24 mo 212 yr Adult CALCIUM (IONIZED) Newborn <36 hr Newborn 3684 hr 118 yr Adult CARBON DIOXIDE (CO2 CONTENT) Cord blood Newborn Premature, 1 wk Infant/child Adult Nonsmoker Smoker Toxic Lethal CHLORIDE (SERUM) Newborn Child/adult 1422 mEq/L 1322 mEq/L 1427 mEq/L 2028 mEq/L 2228 mEq/L 0.5%1.5% of total hemoglobin 4%9% of total hemoglobin 20%50% of total hemoglobin >50% of total hemoglobin 98113 mEq/L 98107 mEq/L 98113 mmol/L 98107 mmol/L 1422 mmol/L 1322 mmol/L 1427 mmol/L 2028 mmol/L 2228 mmol/L 6.211 mg/dL 7.610.4 mg/dL 9.011.0 mg/dL 8.810.8 mg/dL 8.610 mg/dL 4.205.48 mg/dL 4.405.68 mg/dL 4.805.52 mg/dL 4.645.28 mg/dL Sl Units 1.62.8 mmol/L 1.92.6 mmol/L 2.32.8 mmol/L 2.22.7 mmol/L 2.22.5 mmol/L 1.051.37 mmol/L 1.101.42 mmol/L 1.201.38 mmol/L 1.161.32 mmol/L

CARBON MONOXIDE (CARBOXYHEMOGLOBIN)

Conventional Units CHOLESTEROL (see Lipids) C-REACTIVE PROTEIN (Other laboratories may have different reference values)

Sl Units

00.5 mg/dL

CREATINE KINASE (CREATINE PHOSPHOKINASE) (Major sources: myocardium, skeletal muscle, smooth muscle, and brain) Newborn Man Woman CREATININE (SERUM) Cord Newborn Infant Child Adolescent Man Woman 10200 U/L 15105 U/L 1080 U/L 0.61.2 mg/dL 0.31.0 mg/dL 0.20.4 mg/dL 0.30.7 mg/dL 0.51.0 mg/dL 0.71.3 mg/dL 0.61.1 mg/dL 10200 U/L 15105 U/L 1080 U/L 53106 mol/L 2788 mol/L 1835 mol/L 2762 mol/L 4488 mol/L 62115 mol/L 5397 mol/L

ERYTHROCYTE SEDIMENTATION RATE (ESR) Term neonate 04 mm/hr Child Adult (male) Adult (female) FERRITIN Newborn 1 mo 25 mo 6 mo15 yr Adult male Adult female FIBRINOGEN (See Table 136 , p. 348 ) FOLATE (SERUM) Newborn Infant 565 ng/mL 1555 ng/mL 11147 nmol/L 34125 nmol/L 25200 ng/mL 200600 ng/mL 50200 ng/mL 7140 ng/mL 20250 ng/mL 10120 ng/mL 20200 ng/mL 200600 ng/mL 50200 ng/mL 7140 ng/mL 20250 ng/mL 10120 ng/mL 420 mm/hr 115 mm/hr 425 mm/hr

Conventional Units 216 yr >16 yr FOLATE (RBC) Newborn Infant 216 yr >16 yr GALACTOSE Newborn Thereafter -GLUTAMYL TRANSFERASE (GGT) (Major sources: liver [biliary tree] and kidney) Cord Preterm 03 wk 3 wk3 mo 312 mo boy 312 mo girl 115 yr Adult male Adult female GLUCOSE (SERUM) Preterm Newborn, <1 day Newborn, >1 day Child >16 yr HAPTOGLOBIN Newborn >30 days HEMOGLOBIN A1C 1 day 5 days 3 wk 548 mg/dL 26185 mg/dL 5.07.5% total Hgb 77.0 (7.3) 76.8 (5.8) 70.0 (7.3) 19270 U/L 56233 U/L 0130 U/L 4120 U/L 565 U/L 535 U/L 023 U/L 1150 U/L 732 U/L 2060 mg/dL 4060 mg/dL 5080 mg/dL 60100 mg/dL 74106 mg/dL 521 ng/mL 320 ng/mL 150200 ng/mL 751000 ng/mL >160 ng/mL 140628 ng/mL 020 mg/dL <5 mg/dL

Sl Units 1148 nmol/L 745 nmol/L 340453 nmol/L 1702265 nmol/L >362 nmol/L 3171422 nmol/L 01.11 mmol/L <0.28 mmol/L

19270 U/L 56233 U/L 0130 U/L 4120 U/L 565 U/L 535 U/L 023 U/L 1150 U/L 732 U/L 1.13.3 mmol/L 2.23.3 mmol/L 2.84.5 mmol/L 3.35.6 mmol/L 4.15.9 mmol/L 50480 mg/L 2601850 mg/L

HEMOGLOBIN F [MEAN (SD) % TOTAL HGB]

Conventional Units 69 wk 34 mo 6 mo 811 mo Adult IRON Newborn Infant Child Adult male Adult female KETONES (SERUM) Quantitative LACTATE Capillary blood Newborn Child Venous Arterial <27 mg/dL 520 mg/dL 520 mg/dL 514 mg/dL 52.9 (11) 23.2 (16) 4.7 (2.2) 1.6 (1.0) <2.0 100250 g/dL 40100 g/dL 50120 g/dL 65175 g/dL 50170 g/dL 0.53.0 mg/dL

Sl Units

17.944.8 mol/L 7.217.9 mol/L 9.021.5 mol/L 11.631.3 mol/L 9.030.4 mol/L 530 mg/L

0.03.0 mmol/L 0.562.25 mmol/L 0.52.2 mmol/L 0.51.6 mmol/L

LACTATE DEHYDROGENASE (AT 37C) (Major sources: myocardium, liver, skeletal muscle, erythrocytes, platelets, and lymph nodes) 04 days 410 days 10 days24 mo 24 mo12 yr >12 yr LEAD (see pp. 3538) Child LIPASE 090 days 312 mo 111 yr >11 yr LIPIDS
[8]

290775 U/L 5452000 U/L 180430 U/L 110295 U/L 100190 U/L

290775 U/L 5452000 U/L 180430 U/L 110295 U/L 100190 U/L

<10 g/dL 1085 U/L 9128 U/L 10150 U/L 10220 U/L

<0.48 mol/L

Conventional Units Cholesterol (mg/dL) Desirable <170 <200 Borderline 170199 200239 High >200 >240 Desirable <110 <100 LDL (mg/dL) Borderline 110129 100159

Sl Units HDL (mg/dL) High Desirable >130 45 >160 45 Sl Units 0.651.0 mmol/L 275295 mmol/kg 121454 mol/L 73206 mol/L 48109 mol/L 1.452.91 mmol/L 1.452.16 mmol/L 1.451.78 mmol/L 0.871.45 mmol/L 8.2020.03 mmol/L 3.75.9 mmol/L 4.15.3 mmol/L 3.44.7 mmol/L 3.55.1 mmol/L

Child/adolescent Adult MAGNESIUM

Conventional Units 1.32.0 mEq/L <1.5% total Hgb 275295 mOsm/kg 2.07.5 mg/dL 1.23.4 mg/dL 0.81.8 mg/dL 4.59.0 mg/dL 4.56.7 mg/dL 4.55.5 mg/dL 2.74.5 mg/dL
[9]

METHEMOGLOBIN OSMOLALITY PHENYLALANINE Preterm Newborn Adult PHOSPHORUS Newborn 10 days24 mo 24 mo12 yr >12 yr PORCELAIN POTASSIUM Newborn Infant Child Adult PREALBUMIN Newborn 16 mo 6 mo4 yr 46 yr 619 yr PROTEINS Protein Electrophoresis (g/dL) Age Cord Newborn TP 4.88.0 4.47.6 Albumin 2.24.0 3.24.8

3.09.02 mg/dL 3.75.9 mEq/L 4.15.3 mEq/L 3.44.7 mEq/L 3.55.1 mEq/L 739 mg/dL 834 mg/dL 236 mg/dL 1230 mg/dL 1242 mg/dL

-1 0.3 0.7 0.1

-2 0.40.9 0.20.3

0.41.6 0.30.6

0.81.6 0.61.2

Conventional Units 0.3 1 day1 mo 13 mo 46 mo 712 mo 1324 mo 2536 mo 35 yr 68 yr 911 yr 1216 yr Adult 4.47.6 3.67.4 4.27.4 5.17.5 3.77.5 5.38.1 4.98.1 6.07.9 6.07.9 6.07.9 6.08.0 2.55.5 2.14.8 2.85.0 3.25.7 1.95.0 3.35.8 2.95.8 3.35.0 3.25.0 3.25.1 3.15.4 0.1 0.3 0.1 0.4 0.1 0.4 0.1 0.6 0.1 0.6 0.1 0.3 0.1 0.4 0.1 0.5 0.1 0.4 0.1 0.4 0.1 0.4 0.31.0 0.31.1 0.30.8 0.31.5 0.41.4 0.41.1 0.41.0 0.50.8 0.70.9 0.51.1 0.41.1 0.21.1 0.31.1 0.30.8 0.41.0 0.41.4 0.31.2 0.51.0 0.50.9 0.61.0 0.51.1 0.51.2

Sl Units

0.41.3 0.21.1 0.10.9 0.21.2 0.41.6 0.41.5 0.41.7 0.72.0 0.82.0 0.62.0 0.71.7 Sl Units 0.030.10 mmol/L

Conventional Units PYRUVATE RHEUMATOID FACTOR SODIUM Preterm Older Infant Adult TOTAL PROTEIN (See Proteins) TRANSAMINASE (SGOT) (See Aspartate aminotransferase [AST]) TRANSAMINASE (SGPT) (See Alanine aminotransferase [ALT]) 130140 mEq/L 133146 mEq/L 100400 g/dL 250425 g/dL 0.30.9 mg/dL <30 U/mL

130140 mmol/L 133146 mmol/L 17.971.6 mol/L 44.876.1 mol/L

TOTAL IRON-BINDING CAPACITY (TIBC)

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Conventional Units TRANSFERRIN Newborn 3 mo10 yr Adult TOTAL TRIGLYCERIDE (mg/dL) Cord 14 yr Male Female 59 yr Male Female 1014 yr Male Female 1519 yr Male Female TROPONIN-I UREA NITROGEN Premature (<1 week) Newborn Infant/child Adult URIC ACID 02 yr 212 yr 1214 yr Adult male Adult female VITAMIN A (Retinol) Preterm 1346 g/dL 2.46.4 mg/dL 2.45.9 mg/dL 2.46.4 mg/dL 3.57.2 mg/dL 2.46.4 mg/dL 38 36 78 73 88 85 Conventional Units 00.1 g/L 325 mg/dL 412 mg/dL 518 mg/dL 620 mg/dL 33 39 63 72 74 85 28 32 52 64 58 74 29 34 56 64 68 74 5th 14
[10]

Sl Units 1.302.75 g/L 2.033.6 g/L 2.153.8 g/L 90th 85 95 70 103 94 104 125 112 95th 84 99 112 85 126 111 120 143 126

130275 mg/dL 203360 mg/dL 215380 mg/dL Mean 34 75th

Sl Units

1.18.9 mmol/L 1.44.3 mmol/L 1.86.4 mmol/L 2.17.1 mmol/L 0.140.38 mmol/L 0.140.35 mmol/L 0.140.38 mmol/L 0.200.43 mmol/L 0.140.38 mmol/L

0.461.61 mol/L

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Conventional Units Full term 16 yr 712 yr 1319 yr VITAMIN B1 (Thiamine) VITAMIN B2 (Riboflavin) VITAMIN B12 (Cobalamin) Newborn Child/adult VITAMIN C (Ascorbic acid) VITAMIN D3 (1,25-dihydroxy-vitamin D) VITAMIN E <11 yr >11 yr ZINC 315 mg/L 520 mg/L 70120 mg/dL 1665 pg/mL 0.41.5 mg/dL 1601300 pg/mL 200835 pg/mL 424 g/dL 5.37.9 g/dL 1850 g/dL 2043 g/dL 2049 g/dL 2672 g/dL

Sl Units 0.631.75 mol/L 0.71.5 mol/L 0.91.7 mol/L 0.92.5 mol/L 0.160.23 mol/L 106638 nmol/L

118959 pmol/L 148616 pmol/L 2385 mol/L 42169 pmol/L 7.035 mol/L 11.646.4 mol/L 10.718.4 mmol/L

II. EVALUATION OF BODY FLUIDS A. EVALUATION OF TRANSUDATE VERSUS EXUDATE ( Table 252 ) Table 25-2 -- EVALUATION OF TRANSUDATE vs. EXUDATE (PLEURAL, PERICARDIAL, OR PERITONEAL FLUID) Measurement * Transudate Exudate Specific gravity Protein (g/dL) Fluid : serum ratio LDH (IU) Fluid : serum ratio (isoenzymes not useful) WBCs RBCs Glucose <1.016 <3.0 <0.5 <200 <0.6 <1000/mm <10,000
3

>1.016 >3.0 >0.5 >200 >0.6 >1000/mm3 Variable

Same as serum Less than serum

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Measurement * pH

Transudate 7.47.5

Exudate <7.4

LDH, lactate dehydrogenase; RBCs, red blood cells; WBCs, white blood cells. Note: Amylase >5000 U/mL or pleural fluid : serum ratio >1 suggests pancreatitis.
*

Always obtain serum for glucose, LDH, protein, amylase, etc. Not required to meet all of the following criteria to be considered an exudate. In peritoneal fluid, WBC > 800/mm3 suggests peritonitis. Collect anaerobically in a heparinized syringe. B. EVALUATION OF CEREBROSPINAL FLUID ( Table 253 ) Table 25-3 -- EVALUATION OF CEREBROSPINAL FLUID WBC Count Preterm Term Child GLUCOSE Preterm Term Child 025 WBCs/mm 07 WBCs/mm3 2463 mg/dL 34119 mg/dL 4080 mg/dL
3 3

Mean % PMNs 57% 61% 5% 1.33.5 mmol/L 1.96.6 mmol/L 2.24.4 mmol/L

022 WBCs/mm

CSF GLUCOSE/BLOOD GLUCOSE Preterm 55%105% Term Child 44%128% 50%

LACTIC ACID DEHYDROGENASE Normal range 530 U/L (or about 10% of serum value) MYELIN BASIC PROTEIN <4 ng/mL OPENING PRESSURE (Lateral recumbent) Newborn Infant/child Respiratory variations PROTEIN Preterm Term Child 811 cmH2O <20 cmH2O 0.51 cmH2O 65150 mg/dL 20170 mg/dL 540 mg/dL 0.651.5 g/L 0.201.7 g/L 0.050.40 g/L

CSF, cerebrospinal fluid; PMNs, polymorphonuclear lymphocytes; WBC, white blood cell.

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Modified from Oski FA: Principles and Practice of Pediatrics, 3rd ed. Philadelphia, JB Lippincott, 1999. C. EVALUATION OF SYNOVIAL FLUID ( Table 254 ) Table 25-4 -- CHARACTERISTICS OF SYNOVIAL FLUID IN THE RHEUMATIC DISEASES Synovial PM Viscosit Muci WBC Miscellaneou N Group Condition Complemen Color/Clarity y n Clot Count s Findings t (%) Noninflammator Normal y Traumatic arthritis N Yellow Clear N Xanthochromic H Turbid Osteoarthritis N Inflammatory Systemic lupus erythematosu s Rheumatic fever Juvenile rheumatoid arthritis Reiters syndrom Pyogenic Yellow Clear Yellow Clear N Yellow Cloudy N Yellow Cloudy Yellow Opaque Tuberculous N arthritis Yellow-white Cloudy Septic arthritis Serosanguineou s Turbid WBC, white blood cell; PMN, polymorphonuclear leukocyte; N, normal; VH, very high; H, high; G, good; F, fair; , decreased; , increased. From Cassidy JT, Petty RE: Textbook of Pediatric Rheumatology, 4th ed. Philadelphia, WB Saunders, 2001. Poor 50,000 >75 300,00 0 Low glucose, bacteria Poor 25,000 50 60 Acid-fast bacteria Poor 20,000 80 Reiters cells Poor 15,000 75 20,000 F 5000 10 50 N N 5000 10 Lupus erythematosus cellls H FG 1000 <25 FG <2000 <25 Debris VH G <200 <25

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III. CONVERSION FORMULAS A. TEMPERATURE 1. To convert degrees Celsius to degrees Fahrenheit: ([9/5] Temperature) + 32. 2. To convert degrees Fahrenheit to degrees Celsius: (Temperature - 32) (5/9). B. LENGTH AND WEIGHT 1. Length: To convert inches to centimeters, multiply by 2.54. 2. Weight: To convert pounds to kilograms, divide by 2.2.

THYROID TESTS 1. Interpretation of thyroid function tests (see Table 91 ). 2. Thyroid scan: Used to assess thyroid clearance and to study structure and function of the thyroid. Localizes ectopic thyroid tissue and hyperfunctioning and nonfunctioning thyroid nodules. 3. Technetium uptake: Measures uptake of technetium by thyroid gland; levels are increased in hyperthyroidism and decreased in thyroxine-binding globulin (TBG) deficiency and in hypothyroidism (except dyshormonogenesis, when it may be increased).

Table 9-1 -- THYROID FUNCTION TESTS: INTERPRETATION TSH Primary hyperthyroidism Primary hypothyroidism Hypothalamic/pituitary hypothyroidism TBG deficiency Euthyroid sick syndrome TSH adenoma or pituitary resistance Compensated hypothyroidism L H L, N, H * N L, N, H N to H H
[*]

T4 H L L L L H N L L N

Free T4 High N to H

L to low N H N

H, High; L, low; N, normal; T4, thyroxine; TBG, thyroxine-binding globulin; TSH, thyroid-stimulating hormone.
*

Can be normal, slightly low, or slightly high. Treatment may not be necessary.

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B. HYPOTHYROIDISM ( Table 92 ) Table 9-2 -- HYPOTHYROIDISM Disease and Clinical Onset Symptoms PRIMARY/CONGENITAL Large fontanelles, lethargy, constipation, hoarse cry, hypotonia, hypothermia, and jaundice Symptoms usually develop within the first 2 weeks of life and are almost always present by 6 weeks. Deficiency of thyrotropin-releasing T4 hormone (TRH), thyrotropin (TSH) or However, if the cause is other than absence of the thyroid gland, some infants may be relatively asymptomatic. They are still at risk for developmental delay. ACQUIRED Deceleration of growth is often the first manifestation. Other signs may include coarse, Can occur as brittle hair; dry, early as the first Hashimoto thyroiditis T4, TSH scaly skin; and 2 years of life delayed tooth eruption. As above. After 2 years, monitoring levels every 6 to 12 months should be adequate as dose changes become less frequent. Goal of therapy is to achieve T4 levels in the upper half of normal range. If hypothyroidism is due to a primary cause, TSH should be kept <5. Be aware that a minority of infants maintain a persistently high TSH despite correction of the T4level. Replacement with l-thyroxine should begin as soon as diagnosis is confirmed, usually by newborn screens. Monitor T4 and TSH levels at the end of weeks 1 and 2 of therapy.

Etiology

Evaluation

Management

Follow-up

The most common cause is a defect of fetal thyroid development or TSH (athyrosis). Other causes include a mutation in the TSH receptor and thyroid dyshormonogensis.

If levels are adequate, follow every 13 months during the first 12 months.

Replacement with l-thyroxine.

Head/neck radiation

The presence of

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Disease and Clinical Symptoms

Onset

Etiology

Evaluation antithyroglobulin and antimicrosomal antibodies suggests Hashimoto thyroiditis.

Management

Follow-up

Thyroid hormone levels in premature infants are lower than those seen in full-term infants. Further, the TSH surge seen at approximately 24 hours of age in full-term babies does not appear in preterm infants. In this population, lower levels are associated with increased illness, but the effect of replacement therapy remains controversial. C. HYPERTHYROIDISM ( Table 93 ) Table 9-3 -- HYPERTHYROIDISM Disease and Clinical Onset Symptoms Hyperactivity, irritability, altered mood, insomnia, heat intolerance, increased sweating, pruritus, tachycardia, palpitations, fatigue, weakness, weight loss despite increased appetite, increased stool frequency, oligomenorrhea or amenorrhea, fine tremor, hyperreflexia, hair loss

Etiology

Evaluation

Management

Follow-up

The most common cause in childhood is Graves disease (see below). Other causes include Prevalence subacute thyroiditis, increases with factitious age beginning TSH * hyperthyroidism in (intake of adolescence. exogenous hormone), and rarely a TSHsecreting pituitary tumor. Has a 4 : 1 female-tomale predilection. Pituitary resistance to thyroid hormone demonstrates a compensatory rise T4, T3 in T4, but TSH remains within the normal range. Further tests include assessment of TSH receptor stimulating

Treat with Propothiouracil (PTU) or methimazole, which inhibit formation of thyroid hormone.

Follow symptoms and level of T4 and TSH.

Radioactive iodine (131I) is an option for refractory cases.

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Disease and Clinical Symptoms

Onset

Etiology

Evaluation antibody, antithyroglobulin and antimicrosomal antibodies, free T4, and free T3.

Management

Follow-up

Graves disease: Diffuse goiter, a feeling of grittiness and discomfort in the eye, retrobulbar pressure or pain, eyelid lag or retraction, periorbital edema, chemosis, scleral injection, exophthalmos, extraocular muscle dysfunction, localized dermopathy, and lymphoid hyperplasia

Peak incidence between 11 and 15 years of age There is a 5 : 1 female-tomale ratio. Most children with Graves disease have a family history of some form of autoimmune thyroid disease.

Autoimmune

T4 , T3

As above

TSH

Thyroid storm: Acute in onset.

T4 , T3

Propranolol is used to suppress signs and symptoms of thyrotoxicosis. Potassium iodide may also be used for acute hyperthyroid management. Long-term management may include radiation therapy.

Manifested by hyperthermia, tachycardia, and restlessness. Untreated, this may progress to delirium, coma, and death. Neonatal thyrotoxicosis: Microcephaly, frontal bossing, intrauterine growth retardation (IUGR), tachycardia,

TSH

Seen exclusively in Ranges from infants born to immediate to mothers with T4 , T3 delayed for Graves disease. weeks Caused by transplacental

As above

Disease usually resolves by 6 months of age.

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Disease and Clinical Symptoms systolic hypertension leading to widened pulse pressure, irritability, failure to thrive, exophthalmos, goiter, flushing, vomiting, diarrhea, jaundice, thrombocytopenia, and cardiac failure or arrhythmias

Onset

Etiology passage of maternal thyroid-stimulating immunoglobulin (TSI). Occasionally, mothers are unaware that they have Graves disease. Also, note that if a mother has received definitive treatment (thyroidectomy or radition therapy), the possible passage of TSI remains.

Evaluation

Management

Follow-up

TSH

Digoxin may be indicated for heart failure.

With the rare case of a TSH-secreting tumor, the patient does not have hyperthyroidism if the TSH is not suppressed, regardless of the levels of T3 and T4.