Toxic multinodular goitre
Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- goitre
Other diagnostic factors
- heat intolerance, hyperphagia, or weight loss
- depression
- nervousness or palpitations
- oligomenorrhoea
- hyperdefecation
- stare or lid lag
- warm, moist skin
- tachycardia
- irregular pulse
- tremor
- muscle weakness
- shortness of breath or choking sensation
- Pemberton's sign
Risk factors
- iodine deficiency
- age >40 years
- head and neck irradiation
- family history of thyroid nodules
- female sex
Diagnostic investigations
1st investigations to order
- thyroid-stimulating hormone (TSH)
Investigations to consider
- free T4 (or total T4 with measure of binding)
- total T3 with a measure of binding (or free T3)
- I-123 thyroid scan and uptake
- Tc-99 pertechnetate scan
- thyroid ultrasound
- metabolic panel
- FBC
- thyroid peroxidase antibodies
- TSH receptor antibodies
- ECG
- CT neck (non-contrast)
Treatment algorithm
non-pregnant non-lactating adults: without mass effect or suspicion of cancer
mass effect or suspicion of cancer
pregnant or lactating: without mass effect or suspicion of cancer
Contributors
Authors
Elizabeth N. Pearce, MD
Professor of Medicine
Boston University Medical Center
Boston
MA
Disclosures
ENP is a member of the Management Council of the Iodine Global Network. She was the 2018-2019 President of the American Thyroid Association (ATA) and served on its board and executive committee until 2020. She is a current member of the ATA's thyroid in pregnancy guidelines writing task force. She is currently a Deputy Editor at the Journal of Clinical Endocrinology and Metabolism and has previously served as an Associated Editor for the journals Thyroid, Endocrine Practice, and Clinical Thyroidology. She is an author of a number of references cited in this topic.
Acknowledgements
Dr Elizabeth N. Pearce would like to gratefully acknowledge Dr Sheila Feit, a previous contributor to this topic. SF was previously employed by BMJ.
Peer reviewers
Petros Perros, BSc, MBBS, MD, FRCP
Consultant Endocrinologist
Freeman Hospital
Newcastle-Upon-Tyne
UK
Disclosures
PP declares that he has no competing interests.
Ronald Merrell, MD, FACS
Professor of Surgery
Virginia Commonwealth University
Richmond
VA
Disclosures
RM declares that he has no competing interests.
Differentials
- Graves' disease
- Toxic adenoma
- Thyrotoxic phase of painless/lymphocytic thyroiditis
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