甲状腺功能血清学指标结合超声检查在鉴别儿童毒性弥漫性甲状腺肿与慢性淋巴细胞性甲状腺炎中的价值

Value of serological parameters of thyroid function in combination with ultrasound examination for differentiating Graves disease from Hashimoto thyroiditis in children

目的:分析毒性弥漫性甲状腺肿[又称格雷夫斯病(Graves disease,GD)]和慢性淋巴细胞性甲状腺炎[又称桥本甲状腺炎(Hashimoto thyroiditis,HT)]患儿的甲状腺功能血清学指标和超声检查表现,为临床鉴别儿童GD与HT甲状腺功能亢进(甲亢)期提供依据。方法:选取2016年1月至2019年12月间南京医科大学附属儿童医院内分泌科确诊的GD和HT患儿共226例(年龄为7~14岁),其中GD组患儿124例,HT甲亢组患儿38例,HT甲状腺功能减退(甲减)组患儿64例。另选200名同期且年龄匹配的健康体检儿童作为对照组。用电化学发光免疫测定检测患者及对照者的甲状腺功能血清学指标,包括游离三碘甲状腺原氨酸(free triiodothyronine,FT3)、游离甲状腺素(free thyroxine,FT4)、促甲状腺素(thyroid stimulating hormone,TSH)、抗甲状腺过氧化物酶自身抗体(anti-thyroid peroxidase autoantibody,anti-TPOAb)、抗甲状腺球蛋白抗体(anti-thyroglobulin antibody,anti-TGAb)、促甲状腺激素受体抗体(thyroid stimulating hormone receptor antibody,TRAb)。同时记录患者及对照者的甲状腺超声检查指标,包括甲状腺左右叶横径及前后径、峡部前后径和彩色多普勒血流成像(color Doppler flow imaging,CDFI),比较GD组与HT甲亢组间上述临床数据的差异。结果:与HT甲亢组比较,GD组患儿TRAb水平升高[(18.98±20.11)IU/L比(0.33±0.41)IU/L],anti-TPOAb[(176.10±188.84)IU/mL比(219.65±203.66)IU/mL]和anti-TGAb[(242.40±632.15)IU/mL比(471.56±361.12)IU/m]水平降低。进一步分析3种甲状腺自身抗体的阳性率,结果发现,GD组的TRAb阳性率(93%)高于HT甲亢组(33%),HT甲亢组的anti-TPOAb(93%)和anti-TGAb(84%)阳性率高于GD组(52%和49%)(P均<0.05)。与HT甲亢组(35%)相比,GD组CDFI报告血流丰富率高(94%)(P<0.05),余超声指标无差异。结论:儿童GD与HT甲亢期的临床表现相近,超声检查提示肿大甲状腺体积相近;患儿的TRAb水平升高和CDFI报告血流丰富时,多提示为GD;当anti-TPOAb、anti-TGAb水平升高和CDFI报告血流不丰富时,则多提示患儿为HT甲亢期。鉴别二者时,超声CDFI检测血流可提供鉴别GD与HT甲亢期的参考信息。

Objective:To analyze the serological parameters of thyroid function and features of ultrasound examination in pediatric patients with Graves′disease(GD)and Hashimoto thyroiditis(HT)so as to provide evidence for the differential diagnosis of the two diseases.Methods:A total of 226 children(aged from 7-14 years)from January 2016 to December 2019 at Children′s Hospital of Nanjing Medical University were enrolled,including 124 GD children(GD group)and 102 HD(HD group).HD children were further divided into HT with hyperthyroidism(HT with hyperthyroidism group,38 cases)and HT with hypothyroidism(HT with hypothyroidism group,64 cases).Two hundred healthy children with matching age were served as controls.Free triiodothyronine(FT3),free thyroxine(FT4),thyroid stimulating hormone(TSH),anti-thyroid peroxidase autoantibody(anti-TPOAb),anti-thyroglobulin antibody(anti-TGAb)and thyroid stimulating hormone receptor antibody(TRAb)were detected with electrochemiluminescence immunoassay(ECLIA).Indices of ultrasonography including transverse diameter and anteroposterior diameter of right and left lobes of thyroid,isthmic anteroposterior diameter were measured,and blood flow in thyroid was detected by color Doppler flow imaging(CDFI).Both the thyroid function serological parameters and features of ultrasound examination were compared between the four groups.Results:Compared with HT with hyperthyroidism group,GD group had an increased TRAb level[(18.98±20.11)IU/mL vs.(0.33±0.41)IU/L]but lower levels of anti-TPOAb[(176.10±188.84)IU/mL vs.(219.65±203.66)IU/mL]and anti-TGAb[(242.40±632.15)IU/mL vs.(471.56±361.12)IU/mL].A further analysis showed that the positive rate of TRAb in GD group was higher than that in HT with hyperthyroidism group,while HT with hyperthyroidism group had higher positive rates of anti-TPOAb(93%vs 52%)and anti-TGAb(84%vs 49%).Percentage of GD group with rich blood flow detected by CDFI(94%)was higher than that of HT patients with hyperthyroidism group(35%)(P<0.05).Conclusions:GD pediatric patients have similar clinical features and size of thyroid with those of HT with hyperthyroidism,which make it difficult to differentiate.Patients with higher TRAb level and abundant blood flow by CDFI imply a high possibility of GD,while those with increased levels of anti-TPOAb,anti-TGAb and non-abundant blood flow by CDFI are likely to have HT with hyperthyroidism.CDFI may provide reference for distinguishing GD from HT with hyperthyroidism.