Toxic multinodular goitre

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Toxic multinodular goiter
Other namesToxic nodular goiter, Plummer's disease, multinodular toxic goiter, TMNG, MNTG
Causes of hyperthyroidism.png
Most common causes of hyperthyroidism by age. [1]
Specialty Endocrinology

Toxic multinodular goiter (TMNG), also known as multinodular toxic goiter (MNTG), is an active multinodular goiter associated with hyperthyroidism.

Contents

It is a common cause of hyperthyroidism [2] [3] in which there is excess production of thyroid hormones from functionally autonomous thyroid nodules, which do not require stimulation from thyroid stimulating hormone (TSH). [4]

Toxic multinodular goiter is the second most common cause of hyperthyroidism (after Graves' disease) in the developed world, whereas iodine deficiency is the most common cause of hypothyroidism in developing-world countries where the population is iodine-deficient. (Decreased iodine leads to decreased thyroid hormone.) However, iodine deficiency can cause goiter (thyroid enlargement); within a goitre, nodules can develop. Risk factors for toxic multinodular goiter include individuals over 60 years of age and being female. [5]

Signs and symptoms

Symptoms of toxic multinodular goitre are similar to that of hyperthyroidism, including: [5]

Causes

Sequence of events: [6]

  1. Iodine deficiency leading to decreased T4 production.
  2. Induction of thyroid cell hyperplasia due to low levels of T4. This accounts for the multinodular goitre appearance.
  3. Increased replication predisposes to a risk of mutation in the TSH receptor.
  4. If the mutated TSH receptor is constitutively active, it would then become 'toxic' and produces excess T3/T4 leading to hyperthyroidism.

Diagnosis

Hyperthyroidism is diagnosed by evaluating symptoms and physical exam findings, and by conducting laboratory tests to confirm the presence of excess thyroid hormones. It is characterized by high levels of thyroid hormone in the blood along with a low level of thyroid-stimulating hormone (TSH). After diagnosing hyperthyroidism, a thyroid scan can be performed to determine the functionality of the thyroid gland using radioactive iodine. This scan can identify toxic nodules, which appear as a single area of overactivity, as well as toxic multinodular goiter, which presents with multiple areas of overactivity. In addition, a thyroid ultrasound can be conducted to better evaluate the presence of thyroid nodules. [7]

Fine-needle aspiration for cytology is generally not indicated in an autonomously functioning thyroid nodule, as the risk of malignancy is low, and it is generally difficult to distinguishing between a benign lesion and a malignant lesion in such specimens. [8] If thyroidectomy is performed, histopathology can corroborate the diagnosis. Toxic multinodular goiter more or less corresponds to diffuse or multinodular hyperplasia of the thyroid (Grave's disease also shows hyperplasia, but typically more prominent thickening of follicular linings):

Treatments

Toxic multinodular goiter can be treated with antithyroid medications such as propylthiouracil or methimazole, radioactive iodine, or with surgery. [5] Another treatment option is injection of ethanol into the nodules. [9]

A Cochrane review compared treatments using recombinant human thyrotropin-aided radioactive iodine to radioactive iodine alone. [10] In this review it was found that the recombinant human thyrotropin-aided radioactive iodine appeared to lead to a greater of thyroid volume at the increased risk of hypothyroidism. [10] No conclusive data on changes in quality of life with either treatments were found. [10]

History

The usage of terminology for types of goiter has varied over the past century. Physicians and surgeons tend to differentiate among solitary-nodule goiter, multinodular goiter, and non-nodular goiter more thoroughly in recent decades than they formerly did. Thus some sources have described, or still describe, thyroid adenoma (toxic adenoma) as synonymous with toxic multinodular goiter, [11] but other sources differentiate those two as single-nodule disease versus multinodular disease (respectively) with pathogenesis that is likely differing in most cases (e.g., single neoplastic cell clone versus multifocal or diffuse molecular metabolic change). The medical eponyms "Plummer disease" (named after American physician Henry Stanley Plummer [12] ) and "Parry disease" (named after English physician Caleb Hillier Parry) have been used to refer to toxic multinodular goiter, toxic adenoma, and toxic diffuse goiter (Graves' disease); the specific entity in each patient/case is not always clear retrospectively, especially in older literature. This is logical given that advanced medical imaging that can show what is happening at various places within a thyroid gland inside a living person (such as nuclear medicine imaging of radioiodine tracer uptake) was not available until after the 1940s.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Goitre</span> Medical condition

A goitre, or goiter, is a swelling in the neck resulting from an enlarged thyroid gland. A goitre can be associated with a thyroid that is not functioning properly.

<span class="mw-page-title-main">Hyperthyroidism</span> Thyroid gland disease that involves an overproduction of thyroid hormone

Hyperthyroidism is the condition that occurs due to excessive production of thyroid hormones by the thyroid gland. Thyrotoxicosis is the condition that occurs due to excessive thyroid hormone of any cause and therefore includes hyperthyroidism. Some, however, use the terms interchangeably. Signs and symptoms vary between people and may include irritability, muscle weakness, sleeping problems, a fast heartbeat, heat intolerance, diarrhea, enlargement of the thyroid, hand tremor, and weight loss. Symptoms are typically less severe in the elderly and during pregnancy. An uncommon but life-threatening complication is thyroid storm in which an event such as an infection results in worsening symptoms such as confusion and a high temperature; this often results in death. The opposite is hypothyroidism, when the thyroid gland does not make enough thyroid hormone.

<span class="mw-page-title-main">Thyroid</span> Endocrine gland in the neck; secretes hormones that influence metabolism

The thyroid, or thyroid gland, is an endocrine gland in vertebrates. In humans, it is in the neck and consists of two connected lobes. The lower two thirds of the lobes are connected by a thin band of tissue called the isthmus (pl.: isthmi). The thyroid gland is a butterfly-shaped gland located in the neck below the Adam's apple. Microscopically, the functional unit of the thyroid gland is the spherical thyroid follicle, lined with follicular cells (thyrocytes), and occasional parafollicular cells that surround a lumen containing colloid. The thyroid gland secretes three hormones: the two thyroid hormones – triiodothyronine (T3) and thyroxine (T4) – and a peptide hormone, calcitonin. The thyroid hormones influence the metabolic rate and protein synthesis and growth and development in children. Calcitonin plays a role in calcium homeostasis. Secretion of the two thyroid hormones is regulated by thyroid-stimulating hormone (TSH), which is secreted from the anterior pituitary gland. TSH is regulated by thyrotropin-releasing hormone (TRH), which is produced by the hypothalamus.

<span class="mw-page-title-main">Graves' disease</span> Autoimmune endocrine disease

Graves' disease, also known as toxic diffuse goiter, is an autoimmune disease that affects the thyroid. It frequently results in and is the most common cause of hyperthyroidism. It also often results in an enlarged thyroid. Signs and symptoms of hyperthyroidism may include irritability, muscle weakness, sleeping problems, a fast heartbeat, poor tolerance of heat, diarrhea and unintentional weight loss. Other symptoms may include thickening of the skin on the shins, known as pretibial myxedema, and eye bulging, a condition caused by Graves' ophthalmopathy. About 25 to 30% of people with the condition develop eye problems.

<span class="mw-page-title-main">Thyroid neoplasm</span> Medical condition

Thyroid neoplasm is a neoplasm or tumor of the thyroid. It can be a benign tumor such as thyroid adenoma, or it can be a malignant neoplasm, such as papillary, follicular, medullary or anaplastic thyroid cancer. Most patients are 25 to 65 years of age when first diagnosed; women are more affected than men. The estimated number of new cases of thyroid cancer in the United States in 2010 is 44,670 compared to only 1,690 deaths. Of all thyroid nodules discovered, only about 5 percent are cancerous, and under 3 percent of those result in fatalities.

<span class="mw-page-title-main">Thyroidectomy</span> Surgical procedure involving partial or complete removal of the thyroid

A thyroidectomy is an operation that involves the surgical removal of all or part of the thyroid gland. In general surgery, endocrine or head and neck surgeons often perform a thyroidectomy when a patient has thyroid cancer or some other condition of the thyroid gland or goiter. Other indications for surgery include cosmetic, or symptomatic obstruction. Thyroidectomy is a common surgical procedure that has several potential complications or sequelae including: temporary or permanent change in voice, temporary or permanently low calcium, need for lifelong thyroid hormone replacement, bleeding, infection, and the remote possibility of airway obstruction due to bilateral vocal cord paralysis. Complications are uncommon when the procedure is performed by an experienced surgeon.

Thyroid-stimulating hormone (also known as thyrotropin, thyrotropic hormone, or abbreviated TSH) is a pituitary hormone that stimulates the thyroid gland to produce thyroxine (T4), and then triiodothyronine (T3) which stimulates the metabolism of almost every tissue in the body. It is a glycoprotein hormone produced by thyrotrope cells in the anterior pituitary gland, which regulates the endocrine function of the thyroid.

<span class="mw-page-title-main">Hashimoto's thyroiditis</span> Autoimmune disease

Hashimoto's thyroiditis, also known as chronic lymphocytic thyroiditis and Hashimoto's disease, is an autoimmune disease in which the thyroid gland is gradually destroyed. A slightly broader term is autoimmune thyroiditis, identical other than that it is also used to describe a similar condition without a goitre.

The Jod-Basedow effect is hyperthyroidism following administration of iodine or iodide, either as a dietary supplement, iodinated contrast medical imaging, or as a medication.

<span class="mw-page-title-main">Thyroid disease</span> Medical condition

Thyroid disease is a medical condition that affects the function of the thyroid gland. The thyroid gland is located at the front of the neck and produces thyroid hormones that travel through the blood to help regulate many other organs, meaning that it is an endocrine organ. These hormones normally act in the body to regulate energy use, infant development, and childhood development.

<span class="mw-page-title-main">Hürthle cell neoplasm</span> Medical condition

Hürthle cell neoplasm is a rare tumor of the thyroid, typically seen in women between the ages of 70 and 80 years old. When benign, it is called a Hürthle cell adenoma, and when malignant it is called a Hürthle cell carcinoma. Hürthle cell adenoma is characterized by a mass of benign Hürthle cells. Typically such a mass is removed because it is not easy to predict whether it will transform into the malignant counterpart of Hürthle cell carcinoma, which is a subtype of follicular thyroid cancer.

<span class="mw-page-title-main">De Quervain's thyroiditis</span> Medical condition

De Quervain's thyroiditis, also known as subacute granulomatous thyroiditis or giant cell thyroiditis, is a member of the group of thyroiditis conditions known as resolving thyroiditis. People of all ages and genders may be affected.

<span class="mw-page-title-main">Papillary thyroid cancer</span> Medical condition

Papillary thyroid cancer is the most common type of thyroid cancer, representing 75 percent to 85 percent of all thyroid cancer cases. It occurs more frequently in women and presents in the 20–55 year age group. It is also the predominant cancer type in children with thyroid cancer, and in patients with thyroid cancer who have had previous radiation to the head and neck. It is often well-differentiated, slow-growing, and localized, although it can metastasize.

<span class="mw-page-title-main">Sodium/iodide cotransporter</span> Mammalian protein found in Homo sapiens

The sodium/iodide cotransporter, also known as the sodium/iodide symporter (NIS), is a protein that in humans is encoded by the SLC5A5 gene. It is a transmembrane glycoprotein with a molecular weight of 87 kDa and 13 transmembrane domains, which transports two sodium cations (Na+) for each iodide anion (I−) into the cell. NIS mediated uptake of iodide into follicular cells of the thyroid gland is the first step in the synthesis of thyroid hormone.

<span class="mw-page-title-main">Thyroid adenoma</span> Medical condition

A thyroid adenoma is a benign tumor of the thyroid gland, that may be inactive or active as a toxic adenoma.

<span class="mw-page-title-main">Thyroid nodule</span> Medical condition

Thyroid nodules are nodules which commonly arise within an otherwise normal thyroid gland. They may be hyperplastic or tumorous, but only a small percentage of thyroid tumors are malignant. Small, asymptomatic nodules are common, and often go unnoticed. Nodules that grow larger or produce symptoms may eventually need medical care. A goitre may have one nodule – uninodular, multiple nodules – multinodular, or be diffuse.

Thyrotoxic myopathy (TM) is a neuromuscular disorder that develops due to the overproduction of the thyroid hormone thyroxine. Also known as hyperthyroid myopathy, TM is one of many myopathies that lead to muscle weakness and muscle tissue breakdown. Evidence indicates the onset may be caused by hyperthyroidism. There are two known causes of hyperthyroidism that lead to development thyrotoxic myopathy including a multinodular goiter and Graves' disease. Physical symptoms of TM may include muscle weakness, the breakdown of muscle tissue, fatigue, and heat intolerance. Physical acts such as lifting objects and climbing stairs may become increasingly difficult. If untreated, TM can be an extremely debilitating disorder that can, in extreme rare cases, lead to death. If diagnosed and treated properly the effects can be controlled and in most cases reversed leaving no lasting effects.

<span class="mw-page-title-main">Follicular thyroid cancer</span> Medical condition

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<span class="mw-page-title-main">Thyroid cancer</span> Medical condition

Thyroid cancer is cancer that develops from the tissues of the thyroid gland. It is a disease in which cells grow abnormally and have the potential to spread to other parts of the body. Symptoms can include swelling or a lump in the neck. Cancer can also occur in the thyroid after spread from other locations, in which case it is not classified as thyroid cancer.

In CT scan of the thyroid, focal and diffuse thyroid abnormalities are commonly encountered. These findings can often lead to a diagnostic dilemma, as the CT reflects nonspecific appearances. Ultrasound (US) examination has a superior spatial resolution and is considered the modality of choice for thyroid evaluation. Nevertheless, CT detects incidental thyroid nodules (ITNs) and plays an important role in the evaluation of thyroid cancer.

References

  1. ↑ Carlé, Allan; Pedersen, Inge Bülow; Knudsen, Nils; Perrild, Hans; Ovesen, Lars; Rasmussen, Lone Banke; Laurberg, Peter (2011). "Epidemiology of subtypes of hyperthyroidism in Denmark: a population-based study". European Journal of Endocrinology. 164 (5): 801–809. doi: 10.1530/EJE-10-1155 . ISSN   0804-4643. PMID   21357288.
  2. ↑ de Rooij, A; Vandenbroucke, JP; Smit, JW; Stokkel, MP; Dekkers, OM (2009). "Clinical outcomes after estimated versus calculated activity of radioiodine for the treatment of hyperthyroidism: systematic review and meta-analysis". European Journal of Endocrinology . Bioscientifica. 161 (5): 771–777. doi:10.1530/EJE-09-0286. PMID   19671708.
  3. ↑ Krohn, K; Fuhrer, D; Bayer, Y; Eszlinger, M; Brauer, V; Neumann, S; Paschke, R (2005). "Molecular pathogenesis of euthyroid and toxic multinodular goiter". Endocrine Reviews. 26 (4): 504–524. doi: 10.1210/er.2004-0005 . PMID   15615818.
  4. ↑ Reid, JR; Wheeler, SF (2005). "Hyperthyroidism: diagnosis and treatment". American Family Physician. 72 (4): 623–630. PMID   16127951.
  5. 1 2 3 A.D.A.M. Medical Encyclopedia (2012). "Toxic nodular goiter". U.S. National Library of Medicine. Retrieved 30 January 2013.
  6. ↑ Toxic Nodular Goiter at eMedicine
  7. ↑ "Toxic Nodule and Toxic Multinodular Goiter". American Thyroid Association. Retrieved 2023-02-15.
  8. ↑ Philip R Orlander, MD, FACP; Chief Editor: George T Griffing, MD. "Toxic Nodular Goiter Workup". Medscape.{{cite web}}: |author= has generic name (help)CS1 maint: multiple names: authors list (link) Updated: Oct 25, 2021
  9. ↑ J. Larry Jameson; Leslie J. De Groot; David de Kretser; et al., eds. (2010). Endocrinology: adult and pediatric (6th ed.). Philadelphia: Saunders/Elsevier. p. Chapter 82. ISBN   9781416055839.
  10. 1 2 3 Huo, Yanlei; Xie, Jiawei; Chen, Suyun; Wang, Hui; Ma, Chao (2021-12-28). Cochrane Metabolic and Endocrine Disorders Group (ed.). "Recombinant human thyrotropin (rhTSH)-aided radioiodine treatment for non-toxic multinodular goitre". Cochrane Database of Systematic Reviews. 2021 (12). doi:10.1002/14651858.CD010622.pub2. PMC   8712889 . PMID   34961921.
  11. ↑ Elsevier, Dorland's Illustrated Medical Dictionary, Elsevier.
  12. ↑ Plummer's disease eponymously named after Henry Stanley Plummer at Who Named It?
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