Abstract

Objective: Differentiating Graves disease (GD) from Hashitoxicosis in children is often challenging due to overlapping clinical and biochemical features at presentation. This study aimed to evaluate the diagnostic utility of commonly available clinical and biochemical parameters to support etiologic classification in pediatric autoimmune thyrotoxicosis.

Materials and Methods: We retrospectively analyzed 58 children aged 0–18 years diagnosed with autoimmune thyrotoxicosis between 2019 and 2025. Clinical, laboratory, and imaging findings were compared between patients with GD and Hashitoxicosis. Receiver operating characteristic (ROC) analysis and logistic regression were performed to assess the diagnostic performance of key parameters.

Results: The cohort was female-predominant, with similar sex distribution between groups (34/44, 77.3% in GD vs 11/14, 78.6% in Hashitoxicosis). Palpitations were the most common presenting symptom (17, 29.3 %). Incidental detection occurred in 17 (29.3%), of whom 9 (52.9%) had subtle symptoms identified on detailed clinical evaluation. Ophthalmopathy was observed exclusively in GD (13, 29.5%). fT3 levels and the fT3/fT4 ratio were significantly higher in GD than in Hashitoxicosis (p = 0.002 and p = 0.001, respectively). TRAb showed the highest diagnostic performance (AUC = 0.950), followed by fT3 (AUC = 0.856) and the fT3/fT4 ratio (AUC = 0.809). A TRAb cut-off of 2.6 IU/L yielded 75% sensitivity and 100% specificity, whereas fT3 ≥6 pg/mL yielded 93% sensitivity and 46% specificity. Anti-TPO and anti-Tg antibodies showed poor discriminatory value. TRAb remained independently associated with GD (OR = 3.61, p = 0.011). Nine children with Hashitoxicosis (64.3%) were managed without treatment and achieved spontaneous resolution.

Conclusion: Differentiating GD from Hashitoxicosis requires an integrated assessment of clinical features, antibody status, and hormone dynamics. TRAb remains the most informative marker, while fT3 and the fT3/fT4 ratio may provide complementary value. Anti-thyroid antibodies have limited utility for etiologic differentiation. Accurate classification helps guide the management and avoid unnecessary treatment.

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Copyright and license

Copyright © 2026 The Author(s). This is an open access article distributed under the Creative Commons Attribution License (CC BY), which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited.

How to cite

1.
Hürmüzlü Közler S, Kilci F, Sarıkaya E, Özcan Murat N. Differentiating Graves disease from Hashitoxicosis in children: Clinical and biochemical predictors. Turk J Pediatr Dis. 2026;Early View:1-7. https://doi.org/10.12956/TJPD.2026.1340