To the Editor: A 2-y-9-mo-old female presented with dysphagia for solid foods associated with vomiting and drooling of saliva for 7 mo. On examination, she was malnourished and had resting tachycardia. A diffuse symmetric, nontender goiter (grade 1) with soft consistency and smooth surface was palpable. Nervous system examination showed a weak gag refax. There was no ophthalmopathy or obvious muscle wasting. Rest of the examination was normal.
Ultrasonography of the neck revealed a bulky thyroid with heteroechoic echotexture. Thyroid profle showed evi- dence of thyrotoxicosis with elevated free T4: 2.7 ng/dL (0.85–1.75 ng/dL), free T3: 23.69 pg/mL (2.58–4.02 pg/ mL), and suppressed TSH: 0.01 IU/mL (0.35–4.94 uIU/ mL). Elevated TSH receptor antibody: 29.97 IU/L (nor- mal<1.22 IU/L) and difusely increased 99mTc pertechne- Tate uptake on thyroid scintigraphy scan confirmed the pres- ence of Grave disease. The patient was started on ant thyroid drug carbimazole (0.5 mg/kg/d) and showed improvement in symptoms with resolution of dysphagia by 4 wk.
Grave disease is uncommon in children with a prevalence of 0.1–3/100,000 . The initial signs may be nonspecifc leading to a delayed diagnosis . The goiter can be of vari- able size and may go unnoticed . Dysphagia is an uncom- mon presenting symptom of Grave disease and in a review of literature, Chiu et al. found reports of only 13 adults with such a clinical presentation over a 30-y span . Patho- physiologic mechanisms include a massively enlarged thy- roid gland causing mechanical obstruction; and in patients without signifcant thyroid enlargement (as in our child), it is postulated that thyroid hormones exert a direct efect on bulbar muscles by uncoupling oxidative phosphorylation, reducing adenosine triphophate production and decreasing muscle contractility leading to disturbances in oropharyn- geal peristalsis and dysphagia . Complete resolution in dysphagia has been seen following therapy with patients improving within 14 wk (median 2.5 wk) of adequate treat- ment [2, 4].
To conclude, we report an unusual presenting symptom of thyrotoxicosis in a child. One should consider evaluating for hyperthyroidism in unexplained dysphagia.
1. Léger J, Kaguelidou F, Alberti C, Carel JC. Graves’ disease in children. Best Pract Res Clin Endocrinol Metab. 2014;28:233–43.
2. Chiu WY, Yang CC, Huang IC, Huang TS. Dysphagia as a mani- festation of thyrotoxicosis: report of three cases and literature review. Dysphagia. 2004;19:120–4.
3. Ramsay ID. Muscle dysfunction in hyperthyroidism. Lancet. 1966;2:931–4.
4. Noto H, Mitsuhashi T, Ishibashi S, Kimura S. Hyperthyroidism presenting as dysphagia. Intern Med. 2000;39:472–3.