Graves usually 10-20yrs at presentation. 6:1 female. Usually family history of thyroid or other autoimmune disease. Insidious else acute. Palpitations, diarrhoea, heat intolerance, agitation and deteriorating school performance, weight loss. 

Tremor, fidgety, hypertension, goitre (diffuse, smooth), bruit, exophthalmos (rare in kids). Storm can be triggered by infection or non-compliance. Hyperpyrexia, tachycardia. 

Differential

Neonates can get transient hyperthyroidism driven by maternal antibodies – improves after a few months.

Besides Grave disease, other causes of hyperthyroidism are solitary thyroid nodule (adenoma), multinodular goitre, TSH receptor abnormalities. 

Diagnosis

Besides TSH, do free T4 and T3. FT3 useful (T4 can be normal!) for showing T3 thyrotoxicosis (usually due to toxic nodular hyperthyroidism or early Grave).

Thyroid receptor antibodies usually positive. Do TPO also.

Treatment

Carbimazole – Usually 24 months total, TFTs normalise within 12/52 and dose can then be reduced.  Neutropenia as idiosyncratic side effect (so FBC monitoring not helpful!). If mild stop temporarily. Propylthiouracil second line (liver failure, ANCA vasculitis)

Radio-iodine – avoid <10yrs. Can have storm. Need long term thyroxine. 

Surgery – total or near total excision. Risk of malignancy in remnant. Esp large gland. Hypoparathyroidism as transient side effect. Recurrent laryngeal nerve damage. Iodide used pre-operatively to help texture!

Propranolol short term e.g. 3-4 weeks

Block and replace strategy – where you add thyroxine rather than reduce carbimazole? But 2 drugs not 1!

Relapse common, 2/3 within 2yrs, in adults remission unlikely after 2 years but not true in kids. 

Malignancy risk higher in Grave regardless of management…