Pediatr Cardiol 13:89-91, 1992
Pediatric Cardiology 9 Springer-Verlag New York Inc. 1992
Juvenile Autoimmune Thyroiditis and Mitral Valve Prolapse D e n i s e B l u m b e r g , M o n i k a R u t k o w s k i , C h a r l e s Sklar, D i a n a Reggiardo, D e b o r a h F r i e d m a n , and Raphael David Department of Pediatrics, New York University Medical Center, New York, New York, USA S U M M A R Y . An increased incidence of mitral valve prolapse (MVP) has been reported in adult patients with autoimmune thyroid disease. The aim of this study was to assess the incidence of MVP in children and adolescents with juvenile autoimmune thyroiditis (JAT). Cardiac echo studies using M-mode, 2D, and Doppler examinations were performed on 23 patients (21 females, 2 males). The patients were studied at a median age of 12 years (range 5-20 years). Only one patient was found to have evidence suggestive of MVP, an incidence (4.3%) similar to that seen in the normal pediatric population. We, therefore, conclude that the incidence of MVP in children and adolescence with JAT is not increased. K E Y WORDS: Juvenile autoimmune t h y r o i d i t i s - Hashimoto's t h y r o i d i t i s - Mitrai valve prolapse
Mitral v a l v e p r o l a p s e (MVP) has b e e n r e p o r t e d to be m o r e p r e v a l e n t in adult p a t i e n t s with a u t o i m m u n e d i s o r d e r s [2, 6]. This a s s o c i a t i o n has led to s p e c u l a t i o n that mitral v a l v e p r o l a p s e m a y i n v o l v e a n a u t o i m m u n e p r o c e s s [6]. T h e p r e s e n t s t u d y was u n d e r t a k e n to a s s e s s if c h i l d r e n a n d a d o l e s c e n t s with j u v e n i l e a u t o i m m u n e t h y r o i d i t i s (JAT) (Hashim o t o ' s thyroiditis) also h a v e a n i n c r e a s e d i n c i d e n c e of mitral v a l v e p r o l a p s e .
Patients and Methods Twenty-three patients with the diagnosis of juvenile autoimmune thyroiditis who were followed by the Pediatric Endocrinology Department at New York University Medical Center were included in the study. The patients were 5-20 years of age (median 12 years); 21 were female (Table 1). All were euthyroid and otherwise well at the time of the study. Sixteen were receiving lthyroxine, while seven were not receiving any treatment. At presentation, eight patients had been euthyroid, while 15 had been hypothyroid. The patients included in the study had had JAT for a median of 15 months (range 3-116 months). The diagnosis of JAT was based oil criteria described previously [9]. These included: (a) the presence of a symmetrically enlarged, bosselated thyroid gland; (b) the presence in plasma of significant titers of antimicrosomal and/or antithyroglobin anti-
Address offprint requests to: Dr. Raphael David, Department of
Pediatrics, New York University Medical Center, 550 First Avenue, New York, NY 10016, USA.
bodies; and (c) the absence of any findings on history or physical examination that suggested a cause other than JAT. Thyroid studies included measurements of thyroxine (T4), thyroid stimulating hormone (TSH), and triiodothyronine (T3) resin uptake. Serum T4 and TSH values were determined by standard radioimmunoassay techniques. Antimicrosomal antibodies (AMA) and antithyroglobulin antibodies (ATA) were determined by hemagglutination. Antimicrosomal antibody titers of greater than 1 : 100 and ATA titers of greater than 1 : 20 were considered significant. The patients underwent an echocardiographic examination with an ATL 600. The studies were obtained with the patient in a supine or 30 degree L-decubitus position. Standard M-mode, 2D images as well as Doppler examinations of the mitral valve flow were performed. All studies were analyzed in an independent fashion by two experienced pediatric cardiologists. In addition, all studies were reviewed twice within a 6-month interval by one of the cardiologists blinded to previous results. Criteria for the diagnosis of MVP were based on recommendations by Gilbert [3], Warth [10], and Krivokapich [4]. The physical exam was performed by a pediatric cardiologist blinded to the results of the echocardiographic study.
Results T w e n t y - t w o a d e q u a t e M - m o d e a n d 23 a d e q u a t e 2D a n d D o p p l e r studies w e r e o b t a i n e d . N o n e of the Mm o d e tracings was d i a g n o s t i c of M V P . O n e p a t i e n t had 1 + M V P with s u p e r i o r b o w i n g o f the a n t e r i o r MV-leaflet o n the apical f o u r - c h a m b e r view. This
90
Pediatric Cardiology VoI. 13, No. 2, I992
Table 1. Thyroid function at diagnosis
No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Age
5 6 7 8 10 10 10 11 11 11 11 12 13 13 13 14 14 14 15 17 17 17 20
Sex
F F F F F F F F F F F F F F F F M F F F M F F
Thyroid function at diagnosis T4
TSH
AMA
ATA
6.0 6.5 9.9 5.7 7.9 9.8 6.0 6.5 6.4 8.2 6.8 2.8 9.3 4.0 7.2 9.4 8.3 100 2 24 280
I:100
Pediatric Cardiology 9 Springer-Verlag New York Inc. 1992
Juvenile Autoimmune Thyroiditis and Mitral Valve Prolapse D e n i s e B l u m b e r g , M o n i k a R u t k o w s k i , C h a r l e s Sklar, D i a n a Reggiardo, D e b o r a h F r i e d m a n , and Raphael David Department of Pediatrics, New York University Medical Center, New York, New York, USA S U M M A R Y . An increased incidence of mitral valve prolapse (MVP) has been reported in adult patients with autoimmune thyroid disease. The aim of this study was to assess the incidence of MVP in children and adolescents with juvenile autoimmune thyroiditis (JAT). Cardiac echo studies using M-mode, 2D, and Doppler examinations were performed on 23 patients (21 females, 2 males). The patients were studied at a median age of 12 years (range 5-20 years). Only one patient was found to have evidence suggestive of MVP, an incidence (4.3%) similar to that seen in the normal pediatric population. We, therefore, conclude that the incidence of MVP in children and adolescence with JAT is not increased. K E Y WORDS: Juvenile autoimmune t h y r o i d i t i s - Hashimoto's t h y r o i d i t i s - Mitrai valve prolapse
Mitral v a l v e p r o l a p s e (MVP) has b e e n r e p o r t e d to be m o r e p r e v a l e n t in adult p a t i e n t s with a u t o i m m u n e d i s o r d e r s [2, 6]. This a s s o c i a t i o n has led to s p e c u l a t i o n that mitral v a l v e p r o l a p s e m a y i n v o l v e a n a u t o i m m u n e p r o c e s s [6]. T h e p r e s e n t s t u d y was u n d e r t a k e n to a s s e s s if c h i l d r e n a n d a d o l e s c e n t s with j u v e n i l e a u t o i m m u n e t h y r o i d i t i s (JAT) (Hashim o t o ' s thyroiditis) also h a v e a n i n c r e a s e d i n c i d e n c e of mitral v a l v e p r o l a p s e .
Patients and Methods Twenty-three patients with the diagnosis of juvenile autoimmune thyroiditis who were followed by the Pediatric Endocrinology Department at New York University Medical Center were included in the study. The patients were 5-20 years of age (median 12 years); 21 were female (Table 1). All were euthyroid and otherwise well at the time of the study. Sixteen were receiving lthyroxine, while seven were not receiving any treatment. At presentation, eight patients had been euthyroid, while 15 had been hypothyroid. The patients included in the study had had JAT for a median of 15 months (range 3-116 months). The diagnosis of JAT was based oil criteria described previously [9]. These included: (a) the presence of a symmetrically enlarged, bosselated thyroid gland; (b) the presence in plasma of significant titers of antimicrosomal and/or antithyroglobin anti-
Address offprint requests to: Dr. Raphael David, Department of
Pediatrics, New York University Medical Center, 550 First Avenue, New York, NY 10016, USA.
bodies; and (c) the absence of any findings on history or physical examination that suggested a cause other than JAT. Thyroid studies included measurements of thyroxine (T4), thyroid stimulating hormone (TSH), and triiodothyronine (T3) resin uptake. Serum T4 and TSH values were determined by standard radioimmunoassay techniques. Antimicrosomal antibodies (AMA) and antithyroglobulin antibodies (ATA) were determined by hemagglutination. Antimicrosomal antibody titers of greater than 1 : 100 and ATA titers of greater than 1 : 20 were considered significant. The patients underwent an echocardiographic examination with an ATL 600. The studies were obtained with the patient in a supine or 30 degree L-decubitus position. Standard M-mode, 2D images as well as Doppler examinations of the mitral valve flow were performed. All studies were analyzed in an independent fashion by two experienced pediatric cardiologists. In addition, all studies were reviewed twice within a 6-month interval by one of the cardiologists blinded to previous results. Criteria for the diagnosis of MVP were based on recommendations by Gilbert [3], Warth [10], and Krivokapich [4]. The physical exam was performed by a pediatric cardiologist blinded to the results of the echocardiographic study.
Results T w e n t y - t w o a d e q u a t e M - m o d e a n d 23 a d e q u a t e 2D a n d D o p p l e r studies w e r e o b t a i n e d . N o n e of the Mm o d e tracings was d i a g n o s t i c of M V P . O n e p a t i e n t had 1 + M V P with s u p e r i o r b o w i n g o f the a n t e r i o r MV-leaflet o n the apical f o u r - c h a m b e r view. This
90
Pediatric Cardiology VoI. 13, No. 2, I992
Table 1. Thyroid function at diagnosis
No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Age
5 6 7 8 10 10 10 11 11 11 11 12 13 13 13 14 14 14 15 17 17 17 20
Sex
F F F F F F F F F F F F F F F F M F F F M F F
Thyroid function at diagnosis T4
TSH
AMA
ATA
6.0 6.5 9.9 5.7 7.9 9.8 6.0 6.5 6.4 8.2 6.8 2.8 9.3 4.0 7.2 9.4 8.3 100 2 24 280
I:100
