Introduction: Toxic multinodular goitre, first described by H.S. Plummer in 1913, is unremitting and often develops slowly, with more subtle symptoms than Graves’ disease. Cardiac symptoms such as tachycardia, heart failure, or arrhythmia and atrial fibrillation are most frequent. Here we describe a case who presented with symptoms of thyroid enlargement and heart failure. Case report: A 48-year old female presented to us with complaints of dysphagia, hoarseness of voice, breathlessness on exertion and palpitations since one month ago. Furthermore, the patient gave history of swelling of the neck which was initially pea sized and gradually increased to the current size over a period of two months. On examining the swelling of the neck, thyroid gland appears enlarged, firm with multiple nodules. Two-dimensional echocardi- ography revealed a dilated left ventricle with generalized hypokinesia. Com- puted Tomography of the neck suggested enlarged thyroid gland (12.1 cm × 6.5 cm) with heterogenous architecture, and thyroid gland encircling the tra- chea for approximately 270 degree with mass effect. Thyroid scan showed multinodular goitre with multiple hyperfunctioning nodules of both lobes and warm nodules only in left lobe. The patient was diagnosed as multinodular goitre with cardiomyopathy. The patient was treated medically with methi- mazole, propranolol, aspirin, ramipril, sustained release urodeoxycholic acid, rosuvastatin, pantoprazole and multivitamin. The patient underwent near to- tal thyroidectomy with radioactive iodine ablation, as and when required. Conclusion: Patients with toxic multinodular goitre very frequently present with cardiovascular symptoms, which when identified and treated early can reduce the morbidity significantly.
Toxic multinodular goitre is a common complication of its nontoxic precursor, but its precise incidence in the latter disorder is unknown . It usually occurs after the age of 50 years in patients who have had multinodular goitre for many years. It is many more times more common among women, and is almost never accompanied by infiltrative ophthalmopathy. The clinical manifestations tend to differ from those in dffise toxic goitre. Cardiovascular manifestations tend to predominate, possibly because of the age of the patients. These may include atrial fibrillation or tachycardia, with or without heart failure. Weakness and wasting of muscles are common. Emotional lability may be pronounced. Obstructive symptoms are more common than in Graves' disease.
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5.3 days. Post operative stay in hospital has to be reduced. Thyroidectomy can be done as a day care or short stay procedure in our hospital as is the recent trend in developed countries. However, the applicability of these practices to thyroid surgery remains controversial. Day care surgery can be promoted in selected and educated patients as this will be the future of thyroid surgeries. Hyperthyroidism in multinodular goitre was present in 14% of cases. Hyperthyroidism occurs in cases of multinodular goitre in the natural evolution of the disease and the patient must be treated and brought to euthyroid state before surgery.
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Stage 5: The Multinodular goitre is brought about by continued repetition of the process described above, with the result that most of nodules are inactive and incapable to metabolize iodine but among them are few active foci, which are currently supplying normal body requirement. In the hypothesis of Selwyn Taylor, the functioning nodule was a stage in the evolution of all nodular goitre is questioned by Scintiscan studies to determine the function of solitary or dominant thyroid nodule. It has been demonstrated in autonomous micro or macro nodules in the same thyroid gland suggesting that small nodules function in this manner form their origin. Auto radiographic studies with gross autonomous functioning nodule have demonstrated similar functioning micronodules.
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That is to certify “INCIDENCE OF MALIGNANCIES IN THYROIDECTOMISED PATIENTS FOR MULTINODULAR GOITRE” submitted by Dr.S.GOPINATHAN to the faculty of General surgery, The Tamil Nadu Dr.M.G.R. Medical University, Chennai in partial fulfillment of the requirement for the award of M.S. Degree in General Surgery is a bonafide work carried out by him during the period May 2007 to Oct 2009 under my direct supervision and guidance.
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Multinodular goitre is not associated with eye disease, unless in a rare case of Marine–Lenhart syndrome where it coexists with Grave’s disease. Therefore, other causes of exophthalmos need to be ruled out when the eye disease is seen in a patient with multinodular goitre. Confusion can arise in patients with features suggestive of Graves’ ophthalmopathy in the absence of thyroid-stimulating hormone receptor autoantibodies and no evidence of other causes of exophthalmos. Wepresentacaseofmultinodulargoitreinapatientwithexophthalmoswhichflaredupafteriodinecontrast-based study. A 61-year-old Australian presented with a pre-syncopal attack and was diagnosed with toxic multinodular goitre. At the same time of investigations, to diagnose the possible cause of the pre-syncopal attack, computerised tomographic (CT) coronary artery angiogram was requested by a cardiologist. A few days after the iodine contrast-based imaging test was performed, he developed severe eye symptoms, with signs suggestive of Graves’ orbitopathy. MRI of the orbit revealed features of the disease. Although he had pre-existing eye symptoms, they were not classical of thyroid eye disease. He eventually had orbital decompressive surgery. This case poses a diagnostic dilemma of a possible Graves’ orbitopathy in a patient with multinodular goitre.
metabolic, and mental disturbances. Hyperthyroidism occurs in approximately 0.2% of women and 0.02% of men. The predominant two entities (more than 90%) leading to hyperthyroidism are the immunologic activation of follicular thyroid cells by stimulating antibodies (thyroid- stimulating immunoglobulin, TSI) to the receptor for thyroid-stimulating hormone (TSH-R),known as Graves’ disease (GD), and the nonimmunologic hyperthyroidism caused by autonomously functioning thyroid tissue (AFTT). The latter may express different forms: (1) isolated single nodule (autonomous adenoma), (2) multifocal autonomy (multinodular goiter), and (3) disseminated AFTT in diffusely enlarged but also normal-sized thyroid glands. Therefore, the diagnosis of hyperthyroidism requires clarification of the underlying pathophysiological mechanism of the disease. Measurements of serum thyroidal antibodies, ultrasonography, and scintigraphy of the thyroid gland with thyroidal uptake of radioiodine (RI) or technetium pertechnetate are often necessary in the diagnosis of the disease. In two investigations, pathologically high TSIs were found in 2.6% of unselected women and 1.1% of men, sometimes even compatible with GD.
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Harlequin syndrome (HS) is characterized by unilateral facial flushing and sweating induced by exercise or heat . It is considered a benign, idiopathic condition causing failure of the upper thoracic sympathetic chain with sparing of the first (oculomotor) thoracic segment, wherein hard physical working situations are the precipitants . It is known to be associated with brain stem infarcts, superior mediastinal neurinoma, internal jugular vein catheterization, and carotid artery dissection. Increased sweating is a well- described phenomenon in the hyperthyroid patients which resolves after the definitive treatment. We report a case of Harlequin syndrome associated with hyperthyroidism (toxic multinodular goitre). In these cases, it is important that the physician rules out etiological factors like mediastinal tumour, and the patient needs to be advised about the syndrome persisting despite surgery. We present a case of exacerbated Harlequin syndrome in a case of hyperthy- roidism which has not been reported in English literature.
in the thyroid is a definite clinical entity with important pathological significance. When considering the ‘solitariness’ of the nodule, it is necessary to consider the status of opposite lobe. Ignoring palpation of the opposite lobe is likely to lead to a higher incidence of solitary thyroid nodule turning out to be multinodular goitre. The usual presentation of a thyroid nodule is an asymptomatic swelling that is discovered by either the patient or the clinician. Nodules of at least 0.5cm to 1 cm can usually be detected by palpation. 4 The thyroid nodule has been a subject of vigorous controversy with divergent opinions expressed by those who had wide experience in this field. The optional management of thyroid nodule continues to be a course of controversy and the operative intervention recommended by most of surgeons is not always considered divine by some physicians advocating either observation or suppression. 5 The importance of discrete swelling lies in the risk of neoplasm compared with other thyroid swellings.
influence PTC-genesis, then it would be predicted that these factors could interact with existing genetic factors in the thyroid to result in a unique gene expression pro- file that would predispose to PTC. We sought to address this hypothesis in the context of multinodular goitre and unsuspected PTC. We identified a set of patients with apparently benign hyperplastic nodular disease but that harbored occult PTC and those without evidence of thy- roid malignancy. If this hypothesis is true, then a distinct genetic signature might be identified already within the entire thyroid gland and/or within the hyperplastic tissue associated with unsuspected PTC. This eventually could be of great importance for the clinical management of patients with nodular thyroid disease.
Goitre is an enlargement of the thyroid gland which often presents with a conspicuous swelling in the anterio-lateral region of the neck. We prospectively investigated the characteristics of 68 patients who attended our clinics over a 2 years period that previously patronized traditional healers in the course of their disease. Twenty two (32.35%) patients consulted orthodox doctors as their first and point of contact, while forty six (67.64%) patients first consulted traditional healers prior to orthodox doctors’ consultation. The mean age of patients without traditional healers’ consultation was 33 years (±9.2412) which is lower compared to those with prior traditional healers’ consultation whose mean age was 47.95 years (±9.1780 ) (P <0.001). Female sex and patients in low socio economic class tend to consult traditional healers first. The patients’ marital status and religion show no statis significant difference in their pattern of consultation. Better outcomes seen in the patients that consulted orthodox doctors, was the main reason for consulting orthodox doctors by traditional healer consulters. The mean powerful health locus of control for patients with prior traditional healers’ consultation is higher than that of patient without (31.23 (±1.38) vs. 17.41 (±0.361), < 0.001) while the mean internal health locus of control for patients without prior traditional healers’ consultation is higher than that of patients with prior traditional healers’ consultation (29.11(±1.53) vs. 24.32 (±1.61), p < 0.001). The mean chance health locus of control shows no statistical significant difference. Most patients consulting traditional healers do so as a result of erroneous belief about the cause of goitre, immediate access to treatment within their vicinity believe in the expertise of traditional healers.
Finally, hyperthyroid patients have a disproportionate in- crease in T3 compared to T4 levels . Laurberg et al. have found that this probably results from a relative in- crease in type 1 iodothyronine deiodinase activity in hyper- thyroid patients compared to healthy subjects, where type 2 iodothyronine deiodinase accounts for the majority of T3 production [37,38]. Our patient with Marine-Lenhart syn- drome also presented with an increased T3 to T4 ratio of 1.9%. This matches what Laurberg et al. have found in their collective of multinodular toxic goiter. Their patients with thyroid autonomy had a lower T3/T4 ratio compared to those with Graves’ disease (2.0 versus 2.7%) , suggesting that in our patient the autonomous adenoma was the more
Background: Lithium is an integral drug used in the management of acute mania, unipolar and bipolar depression and prophylaxis of bipolar disorders. Thyroid abnormalities associated with treatment with lithium have been widely reported in medical literature to date. These include goitre, hypothyroidism, hyperthyroidism and autoimmune thyroiditis. This current review explores the varied thyroid abnormalities frequently encountered among patients on lithium therapy and their management, since lithium is still a fundamental and widely drug used in psychiatry and Internal Medicine.
heterozygous novel (c.5178delT, p.A1727Hfs*26) and previously described (c.7123G > A, p.G2375R) thyroglobulin (TG) mutations which are the likely cause of fetal goitre in the deceased sibling. TG mutations rarely cause fetal goitre, and management remains controversial due to the potential complications of intrauterine therapy however an amelioration in goitre size may be achieved with intraamniotic T4, and intraamniotic T3/T4 combination has achieved a favourable outcome in one case. A conservative approach, with surveillance, elective delivery and commencement of levothyroxine neonatally may also be justified, although intubation may be required post delivery for respiratory obstruction. Our observations highlight the lethality which may be associated with fetal goitre. Additionally, although this complication may recur in successive pregnancies, our case highlights the possibility of discordance for fetal goitre in siblings harbouring the same dyshormonogenesis-associated genetic mutations. Genetic ascertainment may facilitate prenatal diagnosis and assist management in familial cases.
During 1999 study in same area reported 5.6% goitre prevalence in Rajkot district, while in 2009 study, the total goitre prevalence rate was found 8.8% (grade 1- 7.6%; grade 2-1.2%) indicating that IDD is a mild public health problem. Though the prevalence rate was not high in any of the study and become serious public health problem, still the prevalence rate was increased in last decade in Rajkot district. This may be due to withdrawal of the notification banning the sale of noniodized salt from Gujarat state since January, 2001. 3 During November, 2005, central government
various imaging modalities. Ultrasonography (US) is a frequent technique, especially for evaluation of thyroid nodules because of its cost effectiveness, safety and noninvasiveness.  US is helpful in detecting cancer in thyroid nodules on basis of different features like echogenicity, margins, micro calcifications, size, shape, internal contents and abnormal neck lymph nodes. [18-19] Unfortunately, the US in the files we studied did not have these details. The US results were only consisted of nodules in either the thyroid gland or the lymph nodes (single or multiple) and goiters (single or multiple). Most of the patients in their ultrasound results in our study had multinodular goiter in two lobes (26 patients, 37.1%), 22 patients (31.4%) had a single nodule and 12 patients (17.1%) had multinodular goiter in one lobe. Six patients (8.6%) had a diffuse smooth goiter, 2 patients had multinodular goiter in one lobe and enlarged lymph nodes and only one patient had a single nodule in the thyroid gland and enlarged lymph nodes. (Table 2).
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Solitary nodular toxic goitre / toxic adenoma / autonomous nodule The distinction between multinodular and solitary nodular toxic goitres may be unnecessary but in approximately 5 per cent of thyrotoxic patients a single nodule consisting of hyperplastic epithelia and surrounded by acini in the resting phase is found. There is good correlation between the size of the nodule and the degree of hormone overproduction. Over production of T3, but not T4, is common (T3- toxicosis). Women are more likely than men to be affected with this type of goitre, and its maximum prevalence occurs between the ages of 40 and 60, although children may also be affected.
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A retrospective study was conducted at the Armed Forces Hospital of King Abdul Aziz Airbase in Dhahran during the period of 1st January 2010 through 31st December 2016. The sample size was based on the size of similar studies elsewhere [17, 18]. The records of two hundred and sixty-nine adult Saudi patients with documented thy- roid nodules who underwent fine needle aspiration cytol- ogy were retrieved. Records of non-Saudis, those with incomplete data, patients who underwent partial thy- roid surgery without prior thyroid FNAC, patients diag- nosed with thyroid cancer from lymph node biopsy and patients with known thyroid malignancy were excluded. The socio-demographic data was gathered using a data collection sheet. Ultrasound reports were used to deter- mine the thyroid gland size, the nodule size (≤ 1 cm), the number of nodules (solitary or multinodular), the charac- ter of the nodule (solid, cystic or mixed) and the presence of enlarged cervical lymph nodes. After the application of a local anaesthetic under aseptic conditions, a 22-gauge needle with a 10-mL syringe was used. The tip of the nee- dle was targeted to areas presumed to contain the most cellular material of the thyroid nodule while continuous low pressure suction was applied simultaneously with a to-and-fro movement of the needle within the lesion to get the material in the needle hub. The histology slides were prepared as soon as the specimens were drawn and labelled. A final cytopathology report was obtained after studying each cell block. The thyroid fine needle aspira- tion cytology outcome was reported using the modified Thy classification as shown in Table 1. Exposure to any sort of radiation was documented. The thyroid status (euthyroid, hypothyroidism and hyperthyroidism), thy- roid parameters [TSH, Free T4(FT4), and Free T3(FT3)] were recorded just before the procedure of thyroid FNAC.
Volumetric analysis was performed using the most recent preoperative CT scans available. The date of the scan was recorded and the time between scan and operation calculated. CT scans were obtained using machines in a variety of hospitals. There may have been slight variations in CT protocols. Scans were viewed using CARESTREAM Vue PACS Version 126.96.36.1992 (Carestream Health Inc (Onex Corporation, Canada)). The in-built lesion management tools were used to perform semi-automated segmentation of goitres. The process of segmentation involved tracing around the goitre on an axial slice of the CT scan using the livewire segmentation tool (Fig. 1a). Three methods of tracing were available and could be used together to save time and enable accurate segmentation: 1) moving mouse around goitre allowing software to automatically identify lesion boundary; 2) clicking at key points to assist software in identifying boundaries; 3) holding down click allowed manual line drawing without any input from the software. Once delineated in two or more CT slices the software automatically segmented the goitre in between these slices. This software is mostly used to measure lesions in the lung and liver, and boundaries of goitres tend not to be as clear as these lesions. This along with the multinodular nature of most goitres, meant the software was not always accurate at automatically circumscribing the goitre. Consequently, a lot of manual adjustment was often required to accurately segment the goitre. As the thyroid has two lobes, there were often two or more separate portions that had to be combined using the merge tool. The software automatically calculated the volume of segmented lesions. Studies, including one examining complex brain lesions, have confirmed the accuracy of this software. [24, 25]
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The differential diagnoses of spinal cord schistoso- miasis include neoplastic and other non-neoplastic cord lesions. Like most non-neoplastic cord lesions (transverse myelitis, multiple sclerosis, and infarc- tion), spinal schistosomiasis shows less anatomic dis- tortion than intramedullary cord tumors. Schistoso- mal myelopathy, however, differs from other causes of myelitis in that it commonly affects the lower cord, whereas transverse myelitis commonly affects the midthoracic region (7, 8, 22). Multinodular intramed- ullary contrast enhancement of the distal cord en- abled correct presumptive preoperative MR imaging diagnosis of spinal schistosomiasis in three cases in this study. The association of enhancing peripheral lesions with the intramedullary nodules seen in all cases could represent a possible MR imaging pattern of this disease.