eMedicine Specialties > Endocrinology > Thyroid

Goiter, Lithium-Induced: Differential Diagnoses & Workup

Author: Nicholas J Sarlis, MBBS, MD, PhD, FACP, Medical Director, Department of Oncology-US Medical Affairs Department, Sanofi-Aventis Pharmaceuticals
Coauthor(s): Boaz Hirshberg, MD, Associate Director, CVMD, Pfizer
Contributor Information and Disclosures

Updated: Dec 18, 2008

Differential Diagnoses

Goiter
Goiter, Nontoxic
Hashimoto Thyroiditis
Thyroiditis, Subacute
Thyrotoxicosis

Workup

Laboratory Studies

Confirmation of the diagnosis of lithium-induced goiter is mostly derived from a positive history of prolonged lithium intake and a positive physical examination finding. Determining whether the patient originates from an iodine-deficient area and whether he or she has a positive family history of goiter or other thyroid disorders is important. Laboratory studies, as follow, are indicated to exclude concomitant hypothyroidism and the existence of a thyroid-specific autoimmune process:

  • Serum thyrotropin7,8
    • This is a first-level test.
    • levels higher than normal indicate concomitant hypothyroidism.
  • Circulating antithyroid peroxidase (anti-TPO) and anti-Tg antibodies
    • These are first-level tests.
    • These antibodies indicate the presence of a thyroid-specific autoimmune process and a higher likelihood of hypothyroidism in the future in cases in which thyroid-function test findings are normal. The frequency of positivity of antithyroidal antibodies is higher in lithium-treated patients with either overt or subclinical hypothyroidism than in control subjects with comparable thyrotropin levels.
  • Serum free thyroxine (T4) and total triiodothyronine (T3) tests7,8,9
    • These are second-level tests.
    • Low levels indicate hypothyroidism, although T3 (or even free T3) testing alone is usually insensitive for a diagnosis of hypothyroidism. Furthermore, serum thyrotropin testing is more sensitive for a diagnosis of hypothyroidism than is free T4 testing.
  • Exaggerated response of thyrotropin to thyrotropin-releasing hormone (TRH) stimulation test10
    • This is a third-level test.
    • This test is usually unnecessary and is mostly reserved for research purposes. Findings are positive in patients with hypothyroidism (clinical or subclinical). Of note, TRH is no longer commercially available as a diagnostic agent in the United States, although it can be manufactured in pharmacies of certain academic centers engaged in clinical endocrinology research.

Imaging Studies

  • Thyroid ultrasonography11,12
    • This is a first-level test.
    • Thyroid ultrasonography can be used to quantitate thyroid size and may show a small volumetric increase in persons with lithium-induced goiter.
  • 123 I uptake test
    • This is a second-level test.
    • 123 I uptake may be slightly increased in some patients with euthyroid goiter because of compensation of the gland for decreased coupling and/or iodination despite normal serum thyrotropin levels.123 I uptake is definitely increased in the small percentage of patients who develop lithium-induced thyrotoxicosis.
  • Perchlorate discharge test
    • This is a third-level test.
    • Results are usually normal (negative), and the test is rarely performed outside an academic setting.
  • Iodide-perchlorate discharge test
    • This is a third-level test.
    • This test is seldom indicated. Results are positive in almost all patients on long-term lithium therapy.

Histologic Findings

Biopsy of the thyroid gland is unnecessary in the vast majority of patients with lithium-induced goiter, although the histologic changes that occur in lithium-induced goiter have been studied in a research setting.

Studies of the effects of lithium administration on normal thyroid gland histology in rodents suggest that hyperplasia and colloid depletion occur early in the course of therapy. Eventually, cellular hyperplasia and accumulation of colloid and Tg in supranormal amounts occur. Because lithium inhibits colloid endocytosis (pinocytosis) and iodine efflux from the thyroid, nodules associated with colloid goiter observed in patients on lithium therapy tend to be rich in Tg. In patients with underlying thyroid pathology (eg, multinodular goiter, postthyroiditis changes), histologic features of the underlying pathology are evident.

More on Goiter, Lithium-Induced

Overview: Goiter, Lithium-Induced
Differential Diagnoses & Workup: Goiter, Lithium-Induced
Treatment & Medication: Goiter, Lithium-Induced
Follow-up: Goiter, Lithium-Induced
References
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References

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Further Reading

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Keywords

lithium-induced goiter, thyroid, bipolar, TSH, lithium, hypothyroidism, bipolar disorder, thyroid symptoms, goiter, hypothyroid, thyroid problems, thyroid nodules, thyroid gland, thyroid hormone, manic depression, hypothyroidism symptoms, mood disorders, mood disorder, manic depressive, bipolar treatment, lithium effects, lithium side effects, goiter lithium therapy, lithium treatment, thyroid-stimulating hormone, lithium toxicity, lithium-induced thyromegaly, thyrotropin, thyroglobulin, Tg, cyclic adenosine monophosphate, cAMP, euthyroid goiter, thyrotoxicosis, iodine, iodine deficiency, thyrocytes, bipolar manic-depressive disorder,

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Contributor Information and Disclosures

Author

Nicholas J Sarlis, MBBS, MD, PhD, FACP, Medical Director, Department of Oncology-US Medical Affairs Department, Sanofi-Aventis Pharmaceuticals
Nicholas J Sarlis, MBBS, MD, PhD, FACP is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Physicians, American Federation for Medical Research, American Head and Neck Society, American Medical Association, American Society for Therapeutic Radiology and Oncology, American Society of Clinical Oncology, American Thyroid Association, Association for Psychological Science, Endocrine Society, European Society for Medical Oncology, New York Academy of Sciences, and Royal Society of Medicine
Disclosure: Sanofi-Aventis Salary Employment

Coauthor(s)

Boaz Hirshberg, MD, Associate Director, CVMD, Pfizer
Boaz Hirshberg, MD is a member of the following medical societies: American Dietetic Association
Disclosure: Nothing to disclose.

Medical Editor

Steven R Gambert, MD, MACP, Chairman, Department of Medicine, Physician-in-Chief, Sinai Hospital of Baltimore; Professor of Medicine, Program Director, Internal Medicine Program, Johns Hopkins University School of Medicine
Steven R Gambert, MD, MACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American Geriatrics Society, Association of Professors of Medicine, Endocrine Society, and Gerontological Society of America
Disclosure: Nothing to disclose.

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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Don S Schalch, MD, Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics
Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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