Drexel University College of Medicine

Diseases and Conditions

Toxic nodular goiter

Definition

Toxic nodular goiter involves an enlarged thyroid gland that contains a small rounded growth or growths called nodules. These nodules produce too much thyroid hormone.

Alternative Names

Toxic multinodular goiter; Plummer's disease

Causes, incidence, and risk factors

Toxic nodular goiter arises from an existing simple goiter. It occurs most often in the elderly. Risk factors include being female and over 60 years old. This disorder is never seen in children.

Sometimes patients with toxic multinodular goiter will develop high thyroid levels for the first time after they receive a large amount of iodine through a vein (intravenously). The iodine may be contrast for a CT scan or heart catheterization.

Symptoms

Symptoms are those of hyperthyroidism. However, the bulging eyeballs seen in Graves disease do not occur.

Symptoms include:

• Fatigue
• Frequent bowel movements
• Heat intolerance
• Increased appetite
• Increased sweating
• Menstrual irregularities (in women)
• Muscle cramps
• Nervousness
• Restlessness
• Weight loss

Signs and tests

A physical examination will show one or many nodules in the thyroid. There may be a rapid heart rate.

Other test results:

• Serum thyroid hormone levels (T3, T4) are high.
• Serum TSH (thyroid stimulating hormone) is low.
• Thyroid scan shows that the nodules are taking up increased amounts of radioactive iodine.

Treatment

Treatments include:

• Antithyroid drugs (propylthiouracil, methimazole)
• Radioactive iodine
• Surgery

Beta blockers (propranolol) can control some of the symptoms of hyperthyroidism until thyroid hormone levels in the body are under control.

Expectations (prognosis)

Because toxic nodular goiter is mainly a disease of the elderly, other chronic health problems may influence the outcome of this condition. The elderly person may be less able to tolerate the effect of hyperthyroidism on the heart.

Complications

Heart complications:

• Atrial fibrillation
• Congestive heart failure
• Rapid heart rate

Other complications:

• Bone loss leading to osteoporosis

Thyroid crisis or storm is an acute worsening of hyperthyroidism symptoms. It may occur with infection or stress. Thyroid crisis may cause:

• Abdominal pain
• Decreased mental alertness
• Fever

Immediate hospitalization is necessary.

Complications of having a very large goiter may include difficulty breathing. This is due to pressure on the airway passage that lies behind the thyroid.

Calling your health care provider

Call your health care provider if you have symptoms of this disorder. Follow the health care provider's recommendations for follow-up visits.

Prevention

To prevent toxic nodular goiter, treat hyperthyroidism and simple goiter as your health care provider recommends.

References

Ladenson P, Kim M. Thyroid. In: Goldman L and Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders; 2007:chap 244.

Davies TF, Larsen PR. Thyrotoxicosis. In: Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams Textbook of Endocrinology. 11th ed. Philadelphia, Pa: Saunders Elsevier;2008:chap 11.

Physician Reference

International Classification of Diseases, 9^th Revision (ICD9)

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