eMedicine Specialties > Endocrinology > Thyroid

Goiter, Toxic Nodular: Follow-up

Author: Anu Bhalla Davis, MD, Assistant Professor, Department of Internal Medicine, Division of Diabetes, Endocrinology, and Metabolism, University of Texas Health Science Center at Houston
Coauthor(s): Philip R Orlander, MD, Interim Chair of Medicine, Director of Endocrinology and Metabolism Fellowship, Director and Professor, Department of Medicine, Division of Endocrinology, University of Texas Health Science Center at Houston; Asra Kermani, MBBS, Postdoctoral Fellow, Center for Human Nutrition, University of Texas Southwestern Medical School
Contributor Information and Disclosures

Updated: Jun 4, 2009

Follow-up

Further Outpatient Care

  • After starting PTU or methimazole in patients with toxic nodular goiter (TNG), repeat free T4 or free T4 index measurements at 4-6 weeks. TSH levels rise slower because of suppression by elevated thyroid hormone levels and may take several months to normalize.
  • Radioiodine ablation may take 10 weeks to achieve clinical response. Patients may require treatment with antithyroid drugs and beta blockers in the interim period. Check biochemical evaluation of thyroid function approximately 4 weeks after initial treatment.
  • Patients who undergo total thyroidectomy should be started on levothyroxine at the time of discharge, unless they are clinically hyperthyroid. Evaluate thyroid function 4-6 weeks after surgery. In the case of subtotal thyroidectomy, thyroid hormone replacement is not required; evaluate thyroid function approximately 1 month after surgery.
  • Monitor patients with subclinical hyperthyroidism on initial biochemical evaluation every 6 months for the development of overt hyperthyroidism.

Complications

  • Hyperthyroid complications
    • The most important complications are related to the heart.
    • Cardiomyopathy resulting in severely depressed function may be observed with hyperthyroidism, possibly in relation to persistent tachycardia. Fortunately, cardiomyopathy resolves remarkably with resolution of the hyperthyroid state.
    • Using anticoagulants to treat patients exhibiting atrial fibrillation remains controversial, although it is recommended by many authorities. Atrial fibrillation of long duration that is associated with other anatomical defects of the heart should be treated with warfarin or another suitable anticoagulant.

Prognosis

  • Most treated patients have a good prognosis. A worse prognosis is related to untreated hyperthyroidism. Patients should understand the gravity of hyperthyroidism. If left untreated, hyperthyroidism may lead to osteoporosis, arrhythmia, heart failure, coma, and death. Regular assessment of thyroid function is important in monitoring disease.
  • Na131 I ablation may result in continued hyperthyroidism, with some patients (up to 73% in some studies, depending on the size of the goiter and the dosing of radioiodine) requiring repeated treatment or surgical removal of the gland. Hypothyroidism after radioiodine ablation has been reported in 0-35% of individuals.
  • Iodine-131 ablation may result in continued hyperthyroidism, with some patients (up to 73% in some studies depending on size of goiter and dosing of radioiodine) requiring repeated treatment or surgical removal of the gland. Hypothyroidism after radioiodine ablation has been reported in 0-35% of individuals.
  • Surgical treatment usually consists of a lobectomy of the hyperfunctioning nodule. The rate of hypothyroidism associated with this procedure is very low. Rates of hyperthyroidism recurrence with surgery have been reported to be as low as 0-9%. Larger, multinodular goiters may require total thyroidectomy.

Patient Education

  • Many patients fear abnormal weight gain with the attainment of the euthyroid state. Provide patients with education regarding the role of thyroid hormone in metabolism, as well as the cardiovascular and thromboembolic risks of hyperthyroidism. Also provide guidelines for lifestyle modification that will allow the patient to avoid weight gain.
  • Appraise patients treated with PTU or methimazole of the risk of agranulocytosis and instruct them to contact a physician if they develop a fever, rash, or sore throat, so that a complete blood count (CBC) with differential can be urgently performed.

Miscellaneous

Medicolegal Pitfalls

  • Pregnancy and lactation
    • Radioactive iodine is contraindicated in pregnancy. Thionamides may be used in pregnancy if the mother is clinically thyrotoxic. Untreated thyrotoxicosis is associated with increased maternal mortality and miscarriage rates. Conversely, overly aggressive treatment may result in maternal and neonatal hypothyroidism. Maintain the free T4 level on the higher end of the reference range. TSH may remain suppressed when following this course of treatment.
    • PTU and methimazole transfer across the placenta. The thionamide of choice during pregnancy is PTU, because it appears to have more limited transfer. Cases of cutis aplasia in newborns have been reported with the use of methimazole.
    • Small amounts of PTU and methimazole are secreted in breast milk. The use of these drugs while breast-feeding was previously considered a contraindication. More recently, however, up to 750 mg daily of PTU and up to 20 mg daily of methimazole have not been demonstrated to effect neonatal thyroid function or intellectual development.17,18
  • Although rare, follicular carcinoma of the thyroid may present as a toxic nodule.
 


More on Goiter, Toxic Nodular

Overview: Goiter, Toxic Nodular
Differential Diagnoses & Workup: Goiter, Toxic Nodular
Treatment & Medication: Goiter, Toxic Nodular
Follow-up: Goiter, Toxic Nodular
Multimedia: Goiter, Toxic Nodular
References
Further Reading
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References

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Further Reading

Related eMedicine topics:
 Hyperthyroidism [Endocrinology]
Hyperthyroidism [Pediatrics: General Medicine]
Hyperthyroidism, Thyroid Storm, and Graves Disease
Hypothyroidism [Endocrinology]
Hypothyroidism [Pediatrics: General Medicine]
Iodine Deficiency
Thyroid Dysfunction Induced by Amiodarone Therapy

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Keywords

toxic nodular goiter, goiter, TNG, toxic multinodular goiter, hyperthyroidism, hyperthyroid, Plummer disease, Plummer's disease, toxic uninodular goiter, autonomously functioning thyroid nodule, toxic adenoma, Graves disease, Graves' disease, iodine deficiency, Jod-Basedow phenomenon, Jod-Basedow effect, Jod-Basedow's effect, hyperfunctioning nodule, multinodular thyroid, underlying nontoxic multinodular goiter, amiodarone, amiodarone-induced hyperthyroidism, thyrotoxicosis, apathetic hyperthyroidism, suppressed thyroid-stimulating hormone, TSH, TSH receptors, superior vena cava syndrome, hyperplasia, cyclic adenosine monophosphate, cAMP, thyroxine, T4, iodine-induced hyperthyroidism, triiodothyronine, T3, micronodular growth patterns, follicles, D727E, endothelin-1, ET-1

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Contributor Information and Disclosures

Author

Anu Bhalla Davis, MD, Assistant Professor, Department of Internal Medicine, Division of Diabetes, Endocrinology, and Metabolism, University of Texas Health Science Center at Houston
Disclosure: Nothing to disclose.

Coauthor(s)

Philip R Orlander, MD, Interim Chair of Medicine, Director of Endocrinology and Metabolism Fellowship, Director and Professor, Department of Medicine, Division of Endocrinology, University of Texas Health Science Center at Houston
Philip R Orlander, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American Diabetes Association, Endocrine Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Asra Kermani, MBBS, Postdoctoral Fellow, Center for Human Nutrition, University of Texas Southwestern Medical School
Asra Kermani, MBBS is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robert A Gabbay, MD, PhD, Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, Laurence M Demers Career Development Professor, Penn State College of Medicine; Director, Diabetes Program, Penn State Milton S Hershey Medical Center; Executive Director, Penn State Institute for Diabetes and Obesity
Robert A Gabbay, MD, PhD is a member of the following medical societies: American Association of Clinical Endocrinologists, American Diabetes Association, and Endocrine Society
Disclosure: Novo Nordisk Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching

Pharmacy Editor

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

Managing Editor

Kent Wehmeier, MD, Professor, Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, St Louis University School of Medicine
Kent Wehmeier, MD is a member of the following medical societies: American Society of Hypertension, Endocrine Society, and International Society for Clinical Densitometry
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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