Graves Disease with Exopthalmos and Pretibial Myexdema

This 17-year-old presented with a 1-month history of weight loss, increased appetite, mild insomnia,hand tremor, palpitations, sweating, heat intolerance, and quick loss of temper. The number of dailybowel movements had increased from 1 to 2. There was no family history of thyroid disorders.The patient was in no acute distress. She was 169 mm (66 in) tall (75th percentile) and weighed47 kg (103.4 lb) (10th percentile). Her blood pressure was 120/80 mm Hg and pulse rate, 104 beats per minute. She had lid lag and mild exophthalmos. The thyroid gland was 2 1/2 times the normal size, and a bruit was heard over it.Laboratory investigations revealed a serum thyroid-stimulating hormone level of less than0.05 mU/L (normal, 0.2 to 6 mU/L) and a free thyroxine (T₄) level of 109.1 pmol/L (normal, 8 to 22 pmol/L). Tests for antithyroglobulin and antimicrosomal antibodies were negative. Graves diseasewas diagnosed. The patient was given methimazole, 15 mg bid. She responded well and waseuthyroid in 3 months.Exophthalmos, lid retraction, diffuse enlargement of the thyroid gland, and hand tremor aretypical findings in Graves disease. The patient may also report weight loss, in spite of a good appetite;heat intolerance; restlessness; emotional disturbances; and frequent bowel movements. Peakincidence is in adolescence; about 5% of all patients are younger than 15 years. Girls are affectedmore often than boys, and the conditionis more common among personsof Asian descent. Children withGraves disease are usually tall. Theirbone age is advanced beyond theirchronologic age, but their sexual maturationis normal.