Most common in older patients.
Onset of symptoms is more insidious and symptoms less dramatic than for Graves' disease. Patients may have apathetic hyperthyroidism (minimal signs/symptoms) or sub-clinical hyperthyroidism (isolated thyroid-stimulating hormone suppression).
Spontaneous remission is rare. Definitive treatment, most commonly radioactive iodine, is usually required.
If untreated, complications may include sequelae of hyperthyroidism, such as cardiac dysfunction or bone loss, or tracheal compression by large goitres.
A toxic multinodular goitre (MNG; also known as Plummer's disease) contains multiple autonomously functioning nodules, resulting in hyperthyroidism. These nodules function independently of thyroid-stimulating hormone and are almost always benign. However, non-functioning thyroid nodules in the same goitre may be malignant.
History and exam
Key diagnostic factors
- presence of risk factors
Other diagnostic factors
- heat intolerance, hyperphagia, or weight loss
- nervousness or palpitations
- stare or lid lag
- warm, moist skin
- irregular pulse
- muscle weakness
- shortness of breath or choking sensation
- Pemberton's sign
- iodine deficiency
- age >40 years
- head and neck irradiation
- family history of thyroid nodules
- female sex
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
- thyroid peroxidase antibodies
- TSH receptor antibodies
- CT neck (non-contrast)
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
Elizabeth N. Pearce, MD
Professor of Medicine
Boston University Medical Center
ENP is the 2019-2019 President of the American Thyroid Association. She is an author of a number of references cited in this topic.
Dr Elizabeth N. Pearce would like to gratefully acknowledge Dr Sheila Feit, a previous contributor to this topic. SF was previously employed by BMJ.
Petros Perros, BSc, MBBS, MD, FRCP
PP declares that he has no competing interests.
Ronald Merrell, MD, FACS
Professor of Surgery
Virginia Commonwealth University
RM declares that he has no competing interests.
- Graves' disease
- Toxic adenoma
- Thyrotoxic phase of painless/lymphocytic thyroiditis
- 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
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