JPED Journal

1.      Case Report

A male neonate, born at 39 weeks' gestation, presented with a goiter without other signs of hypothyroidism. a 3-days -old white male, was admitted to theMofidHospital, weighing 2530 gr. At birth, it was noted that he had a soft tissue mass in the neck.

The mother was 26 years old with out any history of using drug and had normal physical examination and normal thyroid function test. Her one other child is in good health and did not have asimilar difficulty in the newborn period (Figure 1).

On admission, the child was active and in no distress. Pulse was 120, respirations 24 and temperature 37^ºC. Fancies was quite unremarkable. His neck was supple and a mass could be seen in the thyroid area, which was soft and not tender the left size was 3×2.5 cm and the right size was 5×3.5 cm. No bruitwas heard over the mass. Remainder of the physicalexamination was negative. Measurements were: height 51 cm, head circumference 35 inches, neck circumference 24 cm, and ratio of upper segment to lower segment1.38.

Laboratory finding showed a leukocyte count of 14900/mm³, with differentials of 77 % neutrophils, 20% lymphocytes. The hemoglobin level and platelet count were normal. TSH was 295 mlu/L (1.1-17) T4 was 1.4 micro gram /dl (9.9-16.6), and F T4 was 0.216 ng/Dl(0.8-1.7). Serum electrolytes, creatinine, albumin, total bilirubin, protein, and osmolality levels were normal.

The chest radiograph was normal. The echo cardiograph and abdominal sonography were normal. The ultrasound of the neck revealed a huge hyper vascular solid mass in neck region in site of thyroid gland that due to hypertrophic thyroid gland (85×73 mm). Technetium thyroid scan reveals; huge enlargement of the thyroid gland with non-homogeneous up take(Imp was multinodular goiter with multiple type of nodular function) (Figure 2).

Oral thyroxine treatment was initiated when the infant was 3 days old and continued for 3 weeks. Treatment was effective in reducing the goiter and hormone concentrations.

2.      Discussion

Congenital Goiter has been observed "In infants born of normal mothers, of those with suspected hyperthyroidism or hypothyroidism, or those who received thiouracil derivatives or iodine's, and of those who did not receive any known goitrogens" [1]. The present case fits well in the category who did not receive any known goitrogens. It has been shown that the human fetal thyroid begins to function at 14 weeks of gestation[2]. On the other hand, thyroxine or triiodothyronine,which are carried in the circulation as a protein complex, do not cross the placenta freely [8,9].

The fetal pituitary presumably secretes excessive amounts of Thyrotrophic Hormone (T.S.H.), which causes a compensatory hyperplasiaof the fetal gland. In most instances, this prevents the appearance of signs of hypothyroidism in the newborn [4].

The association between upper gastrointestinaltract obstruction and hydramnios is well known [10].Congenital goiter not only obstructs the trachea,but at times encircles the esophagus and maycause obstruction. Hydramnios has been reportedin five instances of congenital goiter [11]. In most instances treatment is symptomatic, as in the case presented above. Maintenance of an adequate airway is the first goal. If hyperextension of the neck does not improve the respiratory picture, the child should have a partial, but adequate, resection of the thyroid isthmus [1]to relieve the obstruction. Tracheotomy has been ineffective in treating the obstruction[5,6,12-16].

Congenital Goiter with Hypothyroidism in neonate is rare but should be suspected in a neonate with neck mass.

Figure 1: New Born.

Figure 2:TechnetiumThyroid Scan.

1.       Bongiovanni AM, et al. (1956) JClin Endocrinol 16: 148.

2.       Chapman EM, et al. (1948) Ibid 8: 717.

3.       Freiesleben EandKjerulf-Jensen K (1947) Ibid 7: 47.

4.       Wilkins L (1957) The diagnosis and treatment of endocrine disorders in childhood and adolescence, Charles C Thomas, Publisher, Springfield, III.

5.       Pitt-Rivers R (1950) Physiol. Rev 30: 194.

6.       Vanderlaan JEand Vanderlaan WP (1947) Entdocr inology40: 403.

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8.       Sullivan KM (2008)Increase in congenital hypothyroidism due to inadequate iodine nutrition? Molecular Genetics and Metabolism 93: 485.

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10.    Noimark L and Cox HE (2008)Nutritional problems related to food allergy in childhood. Pediatric Allergy and Immunology 19: 188-195.

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14.    Kirk B, Marinelango PK, Tian K, Dutta A, Smith EE, et al. (2005) Perchlorate and iodine in dairy and breast milk. Environmental Science & Technology 39: 2011-2017.

15.    Pearce EN, Pino S, He X, Bazrafshan HR, Lee SL, et al. (2004) Sources of dietary iodine: bread, cow’s milk, and infant formula in the Boston area. Journal of Clinical Endocrinology & Metabolism 89: 3421-3424.

16.    Lee SL and Roper J (2004) Inadequate iodine supplementation in American multivitamins. Endocrine Practice 10: 46.