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PubMed1998

Management of hyperparathyroidism in an endemic goiter area.

In an endemic goiter area patients with hyperparathyroidism (HPTH) frequently also have thyroid abnormalities. In a retrospective study of 95 patients with HPTH we assessed the diagnostic accuracy of imaging techniques (ultrasonography or radionuclide scanning) for preoperative localization of parathyroid adenomas. Altogether 86% of our patients had goiter, requiring thyroid resections in 37%. For 19 patients the parathyroid exploration was the second or third cervical operation, most of them due to goiter. We found that the overall rate of transient and permanent recurrent nerve paralysis is considerably increased in patients with previous neck surgery (26% vs. 7%). The combination of ultrasonography and radionuclide scanning can lead surgeons to the site of parathyroid lesions responsible for HPTH in 85% of cases, although frequent nodular goiters can produce pitfalls for correct imaging in iodine-deficient countries. In endemic goiter areas preoperative localization studies can be recommended in patients with primary HPTH--for evaluation of thyroid pathology possibly leading to resection or its accuracy in localizing parathyroid adenomas. These studies also seem justified in patients with previously unsuccessful neck explorations for HPTH.

Adolescent↗
PubMed1998

The clonality of nodules in recurrent goiters at second surgery.

INTRODUCTION: Some studies showed that in multinodular goiters clonal and polyclonal nodules coexist. The clonality of nodules in recurrent goiters is, however, still unknown and may contribute to help explain the pathogenesis of this thyroid disease. METHODS AND RESULTS: The clonality of 14 nodules derived from recurrent goiters was assessed by means of an X-chromosome-inactivation method. Of 14 nodules, 10 showed a polyclonal pattern, 3 were clonal and, in 1 case, the result remained unclear. The mean age of the patients with recurrent goiter at the time of their first operation was significantly lower than the mean age of 50 patients who underwent thyroid surgery for the first time over the same period of time (34.6+/-10.9 years vs 53.7+/-13.5 years; P<0.05). The mean interval between first and second operation was 18 years. CONCLUSION: The finding that nodules in recurrent goiters are predominantly polyclonal suggests that these lesions have their origin in a de novo proliferation of different cohorts of thyrocytes due to unknown growth stimulating molecular events.

Adolescent↗
PubMed1998

Cell proliferation and apoptosis of thyroid follicular cells are involved in the involution of experimental non-tumoral hyperplastic goiter.

To assess the involvement of cellular inhibition and the appearance of apoptosis in regression of the hyperplastic thyroid gland towards normality, an experimental design was used to elicit non-toxic goiter by inducing hyperplastic goiter in rats by treatment with methimazole. We performed a morphological and PCNA immunocytochemical study together with in situ end labelling with bromodeoxyuridine in thyroid glands of rats receiving methimazole in their drinking water over 21 days after which they were allowed a recovery period of 0, 12, 24, 36, 48 and 72 h and 7, 14, 21 and 44 days. Serum T3 and T4 levels were found to be very low in the methimazole-treated animals although they increased after the goitrogenic compound had been withdrawn. Inhibition of cell proliferation and the burst of apoptosis play important roles in the regression of hyperplastic goiter in rats. Cell proliferation, which was strongly stimulated during goiter, fell significantly at 24 h, thereafter decreasing gradually as the recovery period progressed. Isolated cases of thyrocyte necrosis were observed ultrastructurally. Light and transmission electron microscopy revealed the existence of thyroid apoptosis with respect to the development of the study over time. Most apoptotic thyrocytes became detached from the follicular epithelium and later underwent cellular degeneration in the follicular lumen. The remaining apoptotic cells retracted their cytoplasm, lost contact with the follicular lumen and became located at the base of the follicles. The percentage of apoptosis showed that during the first week of thyroid involution apoptosis was already present but with low percentages while maximum values were attained at 21 days of survival. Our results suggest that, in the rat, during the return of thyroid follicular cells to normality after methimazole-induced hyperplastic goiter a balance arises between proliferation and cell death and that this balance is due to the inhibition of cellular proliferation and, secondarily, to the appearance of apoptosis, which becomes particularly evident towards the end of the first week after withdrawing the goitrogenic agent.

Animals↗
PubMed1978

Morphologic and functional substrate of thyrotoxicosis caused by nodular goiters.

The pathogenesis of nonimmunogenic thyrotoxicosis caused by nodular goiters--with the exception of true toxic adenoma--was investigated in 11 patients by means of scintigraphic, morphologic and autoradiographic technics. The basic event is the appearance, for unknown reasons, of autonomously functioning follicles which are morphologically indistinguishable from normal follicles. Four basic patterns of intrathyroidal distribution of autonomously functioning follicles are individualized: Type I = multiple individual autonomously functioning follicles scattered throughout the goiter. Type II = clustered autonomous follicles without demarcation from less active parenchyma. Type III = multiple microadenomas. Type IV = autonomous function of the majority of all follicles. In all four types, the autonomous follicles occur without recognizable relation to nodule boundaries. Scintiscans cannot predict the microstructure of these types of goiters. More than one pattern of distribution of autonomously functioning follicles may occur within a single goiter. The growth of thyroid nodules is independent of, and certainly not a prerequisite to, thyrotoxicosis. Rather, the appearance of thyrotoxicosis in this type of multinodular goiter depends on (1) the number of autonomous follicles throughout the gland and (2) their mean hormone-producing capacity per unit of time.

Autoradiography↗
PubMed2005

Karyotypic characterization of 64 nonmalignant thyroid goiters.

Cytogenetic analyses were performed on 64 nonmalignant thyroid goiters (11 common and 53 multinodular goiters) after short-term culture. The majority of goiters (67%) were characterized by a normal karyotype, but in 5 common (45%) and 16 nodular (30%) goiters, small clones with various numerical and/or structural aberrations were found, in addition to many normal cells. Trisomy or tetrasomy 7 was the most frequent numerical aberration, seen in five cases. Deletion of 18p11 was found in four cases, and in three of them as the sole change. Selection and clonal evolution of aneuploid cells present in nonmalignant goiters could underlie progression into adenoma formation.

Adult↗
PubMed2005

The surgical approach to retrosternal goiters: the role of computerized tomography.

OBJECTIVE: To assess preoperative CT scans of patients with a retrosternal goiter, with an objective of identifying features that are likely to predict the need for sternotomy at operation. STUDY DESIGN AND SETTING: A retrospective review of clinical notes and CT scans of patients who underwent thyroidectomy for retrosternal goiter at a large district general hospital in the United Kingdom between 1998 and 2002. RESULTS: Extension of the goiter to the level of the aortic arch, particularly when combined with tracheal involvement or major vessel displacement, increases the likelihood of requiring median sternotomy. CONCLUSIONS: Most retrosternal goiters can be approached through a cervical incision alone. However, extension of the goiter to the level of the aortic arch does appear to increase the likelihood of requiring sternotomy. SIGNIFICANCE: In such cases in which sternotomy is anticipated, the availability of cardiothoracic services would be helpful to avoid patient morbidity.

Adult↗
PubMed1985

Goiter in pregnant teenagers.

Enlargement of the thyroid gland is common in adolescent girls, but there have been no previous reports of the frequency of goiter in pregnant teenagers. This study was undertaken to determine the prevalence of goiter in 309 consecutive pregnant adolescent patients, ages 11 to 19 years, who presented for prenatal care at the University of California (San Diego) Medical Center Teen OB Clinic. Eighteen patients (6%) were found to have a goiter. Subsequent diagnostic tests revealed that 28% of the patients had autoimmune thyroid disorders (chronic thyroiditis or Graves' disease), and the remainder had nontoxic goiters or subacute thyroiditis. Black patients had significantly more thyroid disease than Mexican-American (p less than 0.01) or white patients (p less than 0.005). The incidence of thyroid problems during pregnancy did not differ significantly from that of 600 nonpregnant teenagers who came to the general Adolescent Medicine Clinic for other health problems. Because abnormalities in thyroid function may have potentially adverse implications for mothers and their infants, we recommend careful evaluation of all pregnant teenagers with goiter to assess maternal thyroid function and to provide treatment if necessary.

Adolescent↗
PubMed1997

Fairly elevated incidence of goiter with marginally low urinary iodine in adolescents living in the north-western part of Tunisia.

In order to study the etiology of endemic goiter in the north-western part of Tunisia, we examined 93 adolescents of this region. We measured urinary iodine concentrations, serum total thyroxine, total triiodothyronine, thyrotropin, thyroglobulin and antithyrogobulin antibody concentrations. The adolescents were questioned about their alimentary habits, the origin of their drinking water and the presence of known goiter(s) in their family. Among these adolescents, 49.5% of them had a goiter. Urinary iodine concentrations showed mild iodine deficiency. The serum determinations gave results within the reference ranges, without any significative differences between adolescents, with or without goiter. We found two risk factors: the age of adolescents, and the presence of a known goiter in the family. These results suggest that the actual prevention may not be adequate, or most likely that goitrogenic factors are to be looked for, especially in drinking water, since the majority of these adolescents drink no controlled water.

Adolescent↗
PubMed2002

Goiter prevalence, urinary iodine excretion, thyroid function and anti-thyroid function and anti-thyroid antibodies after 12 years of salt iodization in Shahriar, Iran.

OBJECTIVE: In a previous study in 1983, goiter was found to be endemic in Shahriar, Iran. Iodized salt has been distributed in the region for the past 12 years, and the present study was performed to examine the effect of iodide supplementation on indicators of iodine deficiency (IDD) and thyroid antibodies. DESIGN & METHODS: A total of 3164 people, 58% women and 42% men, were selected by random sampling from the Shahriar area. Goiter was staged according to World Health Organization guidelines. Urinary iodine was measured by a digestion method, and thyroid hormone measurements were done by radioimmunoassay. The results were compared with those of 1983. RESULTS: Goiter prevalence before and after iodine supplementation was 50 and 40% in men, 70 and 51% in women, and 60 and 47% in the whole community, respectively (p < 0.001). A decrease in the prevalence of goiter was observed especially in younger individuals. The mean urinary iodine excretion was 7.6 and 18.5 micrograms/dL, before and after iodine supplementation. In 1983, the urinary iodine in 47.5% of the population studied was between 2 to 5 micrograms/dL, while in 1995, 65% of the population studied had urinary iodine between 10 to 25 micrograms/dL, 12 years after iodine supplementation. Mean serum T4, T3, and thyroid-stimulating hormone (TSH) were normal before and after intervention. There was no significant change in occurrence of positive antibodies, or of hypo- and hyperthyroidism, following iodine supplementation. CONCLUSION: The result of this study shows that the use of iodized salt causes an increase in excreted urinary iodine and a decrease in the prevalence of thyroid goiter, especially in younger age groups. Consumption of iodized salt with 40 parts per million (ppm) iodine has not caused increased prevalence of thyroid dysfunction in this area.

Adolescent↗
PubMed2002

The relation between serum ferritin and goiter, urinary iodine and thyroid hormone concentration.

OBJECTIVE: Many children are at high risk of both goiter and iron deficiency in Iran. Because iron deficiency may impair the efficacy of iodine supplementation, the aim of this study was to determine the relation between serum ferritin and goiter, urinary iodine, and thyroid hormones following iodized salt supplementation. DESIGN: A cross-sectional study of schoolchildren in 26 Iranian provinces. METHODS: In a national iodine deficiency disorders (IDD) monitoring program, 36,178 schoolchildren, approximately 1200 from each province, received goiter grading by WHO criteria. Urine and serum samples were collected from 2917 children and assayed for urinary iodine and serum ferritin, T4, T3, and thyroid-stimulating hormone (TSH) concentrations. RESULTS: Total goiter rates were 80 and 20% in children with ferritin concentrations < 10 mg/dL and > or = 10 mg/dL, respectively (p < 0.001). Increased serum T3 and decreased resin T3 uptake was present in those with lower serum ferritin levels; however, free T3 and T4 index, serum T4, and TSH were not significantly different between those with low and normal ferritin. CONCLUSION: Iron deficiency is associated with a high prevalence of goiter in Iranian schoolchildren.

Child↗
PubMed2003

High serum circulating telopeptide type I in multinodular goiter.

Recently, concentrations of serum carboxy-terminal-1-telopeptide (ICTP), a marker of bone collagen resorption, were found to be more sensitive than sex hormone-binding globulin (SHBG) in identifying peripheral overexposure to thyroid hormones in exogenous subclinical hyperthyroidism. The aim of the present study was to assess serum ICTP and SHBG in multinodular goiter with (pretoxic goiter) or without biochemical evidence of endogenous subclinical hyperthyroidism. Forty-five women affected by multinodular goiter were enrolled in this study. They were subdivided into two groups: group 1, consisting of 27 patients affected by pretoxic goiter; group 2, consisting of 18 patients affected by non toxic goiter; group 3, consisting of thirty-six euthyroid women matched with the other groups for age and lifestyle. In group 1, serum ICTP (mean +/- SD: 5.8 +/- 2.9 microg/l) concentrations were significantly higher when compared either to group 2 (3.6 +/- 1.2 microg/l; p < 0.02) or controls (2.7 +/- 0.7 microg/l; p < 0.0001); serum ICTP concentrations were also slightly but significantly higher in patients of group 2 compared to controls (p < 0.003). In contrast, mean serum SHBG concentrations did not show any difference among the three groups. No significant correlation was found between serum TSH and ICTP concentrations, while a weak positive correlation (p < 0.05) was only found between serum FT 3 and ICTP concentrations when data from the two patient groups were analyzed together. Moreover, when we subdivided patients into pre- and postmenopausal patients, we observed that SHBG but not ICTP serum concentrations were influenced by estrogenic status. In summary, the measurement of serum ICTP seems to be more suitable than SHBG for identifying those with a higher degree of peripheral thyroid hormone exposure in women affected by endogenous subclinical hyperthyroidism.

Adult↗
PubMed1996

Amyloid goiter: radiological study in a case presenting hypothyroidism.

We report herein a case of amyloid goiter associated with rheumatoid arthritis in which hypothyroidism was observed. A 52-year-old housewife who had suffeed from rheumatoid arthritis for 15 years was referred to our hospital because of general fatigue. On admission, a large goiter was observed. Laboratory data showed primary hypothyroidism. Renal biopsy and gastric mucosa biopsy showed amyloid deposition of AA-type. Thyroid biopsy showed massive amyloid involvement. Although the findings of iodine-123 scintigraphy, technetium-99m pertechnetate scintigraphy, computed tomography and magnetic resonance image studies were similar to those for goiter associated with chronic thyroiditis, tallium-201 chloride scintigraphy gave a differing result, demonstrating absent uptake at 3 hours in this case. Replacement therapy with levothyroxine relieved the symptoms. This case was unusual in that amyloid goiter presented clinically as hypothyroidism. Absence of tallium-201 chloride uptake at 3 hours may be a diagnostic specificity for amyloid goiter in differentiating its hypothyroidism from that caused by chronic thyroiditis.

Amyloid↗
PubMed2002

Current treatment of nodular goiter with hyperthyroidism (Plummer's disease): surgery versus radioiodine.

BACKGROUND: First described 9 decades ago by H. S. Plummer, thyroidectomy and radioiodine remain the 2 therapeutic modalities for toxic nodular goiter. The aim of this study was to determine its optimal treatment. METHODS: The presentation, operative treatment, pathology, and clinical course of 362 consecutive patients treated at our institution for Plummer's disease from 1990 to 1999 were retrospectively reviewed. RESULTS: Three hundred forty-six patients (63 men and 283 women) were treated surgically (181, 53%), with radioiodine (RAI, 157, 45%), or a combination of both (8, 2%). Mean age was 62 years (surgical, 55 years; RAI, 69 years). Nearly half were symptomatic, 51 (15%) with airway or swallowing compromise and 110 (32%) with cardiac complications. The estimated goiter size was larger (60 g or greater) in surgical (72 patients, 38%) than medically treated (45 patients, 29%) patients. RAI treatment dose averaged 28 mCi; 10 patients (6%) required a second treatment, and 8 patients failed treatment and required subsequent thyroidectomy. Types of thyroidectomy included total (29 patients, 16%), near-total (47 patients, 26%), bilateral subtotal (46 patients, 25%), and unilateral (58 patients, 32%). One month after treatment, hyperthyroidism had resolved in 96% of the surgical patients but only 6% of the RAI patients (mean time to resolution, 5.4 months). Only 55 (38%) of the RAI patients' goiters reduced in size. Recurrent laryngeal nerve paralysis and hypoparathyroidism each occurred in 3 (2%) patients. CONCLUSIONS: Surgical treatment results in rapid, reliable resolution of hyperthyroidism and removal of the nodular goiter with low morbidity and no mortality. RAI is also safe and effective, usually requiring a single dose, but the results are delayed and it usually fails to resolve a goiter.

Adolescent↗
PubMed2001

Amyloid goiter as the initial manifestation of systemic amyloidosis due to familial mediterranean fever with homozygous MEFV mutation.

We describe a case of amyloid goiter revealing a systemic amyloidosis secondary to familial Mediterranean fever (FMF) with homozygous MEFV mutation, and we review the literature. A 45-year-old euthyroid Sephardic man, known to suffer from FMF, developed a goiter with cold nodule, after which a subtotal thyroidectomy was performed. Histologic evaluation revealed diffuse AA amyloid deposition without any associated thyroid neoplasia. At that time, no other organ was found to be affected by amyloidosis. Colchicine and levothyroxine were prescribed. Eight years later, the patient presented with a rapidly growing neck enlargement. He reported that he had discontinued colchicine therapy 2 years earlier. The serum thyrotropin (TSH) and calcitonin levels were normal. Renal, digestive, and salivary gland biopsies confirmed the presence of systemic AA amyloidosis. Despite the reintroduction of colchicine, the onset of compressive symptoms led to the completion of the total thyroidectomy. The histopathology again demonstrated amyloid deposition, and excluded a malignant neoplasm. Nine cases of amyloid goiter associated with FMF have been reported in the literature; none of them had an amyloid goiter as the first manifestation of systemic amyloidosis. To our knowledge, this is the first case of FMF in which an amyloid goiter preceded the development of secondary systemic amyloidosis. The cessation of colchicine therapy may have played a role in local relapse and the secondary spread of amyloid deposits.

Amyloidosis↗
PubMed2002

99mTc-MIBI radio-guided minimally invasive parathyroidectomy: experience with patients with normal thyroids and nodular goiters.

The surgical approach to primary hyperparathyroidism (HPT) is changing. In patients with a high probability to be affected by a solitary parathyroid adenoma (PA), a unilateral neck exploration (UNE) or a minimally invasive radio-guided surgery (MIRS) using the intraoperative gamma probe (IGP) technique have recently been proposed. We investigated the role of IGP in a group of 84 patients with primary HPT who were homogeneously evaluated before surgery by a single-day imaging protocol including 99mTcO4/MIBI subtraction scan and neck ultrasound (US) and then operated on by the same surgical team. Quick parathyroid hormone (QPTH) was intraoperatively measured in all cases to confirm successful parathyroidectomy. In 70 patients with scan/US evidence of a single enlarged parathyroid gland (EPG) and with a normal thyroid gland, MIRS was planned. In the other 14 patients, the IGP technique was utilized during a standard bilateral neck exploration (BNE) because of the presence of concomitant nodular goiter (11 cases) or multiglandular disease (MGD) (3 cases). The IGP technique consisted of the following: (1) in the operating room, a low 99mTc-MIBI dose (37 MBq) was injected intravenously during anesthesia induction; (2) subsequently, the patient's neck was scanned with the probe by the surgeon to localize the cutaneous projection of the EPG; (3) in patients who underwent MIRS, the EPG was detected intraoperatively with the probe and removed through a small, 2 to 2.5 cm skin incision; (4) radioactivity was measured on the EPG both in vivo and ex vivo, the thyroid, the background and the parathyroid bed after EPG removal. In patients with concomitant nodular goiter, the radioactivity was also measured on the thyroid nodules. Surgical and pathologic findings were consistent with a single PA in 78 patients, parathyroid carcinoma in 2, and MGD in 4. MIRS was successfully performed in 67 of the 70 patients (97.7%) in whom this approach was planned. It must be pointed out that the IGP technique was particularly useful in detecting the PAs located in ectopic site (5 in the upper mediastinum, 2 at the carotid bifurcation) and deep in the neck (6 in the paratracheal/paraesophageal space). Moreover, MIRS was also successfully performed in the seven patients who had undergone previous parathyroid or thyroid surgery. In the other 3 of 70 patients (4.3%), a conversion to BNE was required because a parathyroid carcinoma (2 cases) and a MGD (1 case) were diagnosed during surgical intervention. It is worth noting that in this latter patient affected by MGD, in contrast with the other patients from our series, QPTH remained elevated after the removal of the preoperatively visualized EPG suggesting the persistence of occult hyperfunctioning parathyroid tissue, and another contralateral EPG was found at BNE. Regarding the group of patients in whom a BNE was planned, the IGP helped the surgeon to localize a supernumerary EPG ectopic in the thymus in a patient with MGD, and to localize a PA ectopic to the right carotid bifurcation in a patient with nodular goiter. However, it has to be pointed out that it was difficult for the surgeon to differentiate intraoperatively with the probe the radioactivity of the EPG from that of thyroid nodule(s) in the other 10 patients with HPT with a concomitant nodular goiter, particularly in 6 patients in whom 99mTc-MIBI uptake was higher in thyroid nodule(s) than in EPG. On the basis of these data we can conclude that: (1) in patients with primary HPT with a high scan/US probability to be affected by a single PA and with a normal thyroid gland, IGP appears to be an useful technique with the aim of performing MIRS; (2) a 99mTc-MIBI dose as low as 37 MBq appears to be adequate to successfully perform MIRS; (3) the measurement of QPTH is strongly recommended in patients with HPT selected for MIRS to confirm complete removal of hyperfunctioning parathyroid tissue; (4) MIRS can be useful also in patients with HPT who previously received parathyroid/thyroid surgery with the aim of limiting surgical trauma at reoperation and minimizing the related risk of complications; (5) with the exception of PA located in ectopic sites, IGP does not seem to be a recommendable technique in patients with HPT concomitant nodular goiter.

Adenoma↗
PubMed1994

Thyroid peroxidase in dyshormonogenetic goiters with organification and thyroglobulin defects.

Thyroid peroxidase (TPO) iodide and guaiacol oxidation activities were evaluated in eight dyshormonogenetic goiters. Two of these had a defective thyroglobulin; the TPO iodide oxidation (431 and 316 U/g ptn) and iodination (31 and 8.6 nmol I/mg ptn) activities were within the normal ranges. The goiters from two siblings with positive perchlorate iodide discharge tests also had normal TPO iodide oxidation (602 and 299 U/g ptn) and iodination activities (44 and 11 nmol I/mg ptn). No TPO iodide oxidation activity was found in the goiters from the other four patients with positive perchlorate iodide discharge tests, and TPO iodide oxidation inhibitory activities were detected in both their TPO and thyroglobulin preparations. Three of them had some TPO guaiacol oxidation activity and did not inhibit normal guaiacol oxidation. The TPO preparation immunoblot of these three goiters showed a faintly visible band of normal 100 kDa TPO. However, in the other patient no guaiacol oxidation activity was detected, and only two bands of low-molecular-weight TPO (72 and 43 kDa) were found, again showing that iodine organification defects in dyshormonogenetic goiters can be due to either qualitative or quantitative TPO defects. The TPO inhibition diminished when iodide was increased in the assay, but was not altered by increasing cofactor (H2O2). Our results, so far, suggest that the TPO-inhibitory substance may interact reversibly with a specific iodide site on the enzyme or with the oxidized form of iodide, and/or could bind free iodide, making it unavailable for enzymatic oxidation.

Blotting, Western↗
PubMed1995

Amyloid goiter in cystic fibrosis.

Chronic infectious or inflammatory diseases lead to amyloid infiltration and dysfunction of many organs, including the kidney, liver, heart, and gastrointestinal tract. Subclinical amyloid infiltration of the thyroid gland has been described in over 80% of such patients. However, symptomatic involvement of the thyroid gland by amyloid is rare. We describe a euthyroid patient with cystic fibrosis and widespread amyloidosis who presented with a rapidly enlarging goiter and symptoms of local compression that compromised his pulmonary status. Fine needle aspiration of the goiter was nondiagnostic. At surgery he proved to have replacement of the thyroid gland by amyloid. A review of the literature reveals only five previous cases of amyloid goiter in patients with cystic fibrosis. However, as more patients survive into adulthood, amyloid goiter may become a more common complication of cystic fibrosis. In contrast to other patients with reactive amyloidosis and goiter, patients with cystic fibrosis may require thyroid surgery to relieve airway compression that can compromise pulmonary function.

Adult↗
PubMed1997

Autoimmune hyperthyroidism occurring late after radioiodine treatment for volume reduction of large multinodular goiters.

131I treatment is an effective alternative to surgery in patients with a large, (non-)toxic, compressive goiter. Late development of hyperthyroidism after 131I therapy for nontoxic nodular goiter is considered rare. We have seen this complication in 3 of approximately 80 patients treated with radioiodine for volume reduction of a large, multinodular goiter. Three women, aged 60 to 71 years, had large, multinodular goiters causing tracheal compression. They were clinically euthyroid before 131I therapy and had normal free thyroxine (FT4) levels. Serum thyroid-stimulating hormone (TSH) levels were normal in 2 patients and undetectable in 1 patient. Patients 1 and 2 received a single dose of 86 and 48 mCi 131I, respectively. Patient 3 received 20 mCi 131I twice (interval 1 month). Clinical and biochemical thyrotoxicosis with high thyroid radioactive iodide uptake (RAIU) developed 10, 6, and 3 months after 131I therapy, respectively, although at control visits 1 to 3 months earlier, serum TSH and FT4 levels were normal. Thyrotoxicosis responded well to methimazole in all three patients. The late occurrence of thyrotoxicosis, high RAIU, and good response to methimazole argue against thyroiditis as the cause of thyrotoxicosis. Serum levels of TSH receptor antibodies, which were undetectable before therapy (patients 1 and 2), were clearly elevated in all three patients during thyrotoxicosis. This is in favor of autoimmune hyperthyroidism as the cause of thyrotoxicosis. These cases illustrate that severe autoimmune hyperthyroidism may occur several months after radioiodine treatment for nontoxic, multinodular goiter. Information about symptoms of hyperthyroidism and regular control visits in the first year after therapy are important in these patients.

Aged↗