Toxic multinodular goitre

Last reviewed: 25 Aug 2022
Last updated: 20 Sep 2019

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • goitre
More key diagnostic factors

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
Other diagnostic factors

Risk factors

  • iodine deficiency
  • age >40 years
  • head and neck irradiation
  • family history of thyroid nodules
  • female sex
More risk factors

Diagnostic investigations

1st investigations to order

  • thyroid-stimulating hormone (TSH)
More 1st investigations to order

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)
More investigations to consider

Treatment algorithm

ONGOING

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 the 2019-2019 President of the American Thyroid Association. 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.

  • Toxic multinodular goitre images
  • Differentials

    • Graves' disease
    • Toxic adenoma
    • Thyrotoxic phase of painless/lymphocytic thyroiditis
    More Differentials
  • Guidelines

    • Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum
    • 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer
    More Guidelines
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