Case Report of Postpartum Thyroid Nodule Size Reduction

Abstract Introduction: Thyroid nodules are very common. They occur more commonly in women with an increased prevalence of thyroid nodules reported in pregnancy. Most thyroid nodules diagnosed during pregnancy are benign. Pregnancy causes major physiological changes including changes in the levels of thyroid hormones and the elevation of thyroid binding globulin. Thyroid nodules may also occur in people with abnormal thyroid function tests manifesting as hyperthyroidism or hypothyroidism. We present a unique case of a new diagnosis of a large thyroid nodule that has significantly decreased in size after 20 months postpartum. Case description: Patient is a 31 year old female with past medical history of anxiety and white coat hypertension who was diagnosed with a 3.3 x 2.3 x 2.1 cm thyroid nodule a month following delivery. Patient did not have any abnormalities in her thyroid function tests before, during, or after pregnancy. She remained euthyroid throughout the pregnancy and in the postpartum period. Fine needle aspiration biopsy of the nodule showed atypia of undetermined significance (Bethesda Category III). The specimen was further analyzed by afirma testing that confirmed benign pathology. Twenty months postpartum, the thyroid nodule significantly decreased in size to 1.9 x 1.4 x 1.2 cm. Conclusion: Thyroid hormone levels physiologically change during pregnancy and this may affect the growth of thyroid nodules. We just presented a patient who exhibited a significant decrease in the size of her thyroid nodule. Sahin et al. showed that while the size of the thyroid nodule increases during pregnancy the number of nodules remains unaffected. Kung et al. showed that pregnancy is associated with an increase in the size of preexisting thyroid nodules as well as the number of newly developed thyroid nodules. Vanucchi et al. showed that although the thyroid gland becomes larger, particularly in late pregnancy, the sizes of any preexisting thyroid nodules remained unchanged and patients’ thyroid gland size returned to normal after delivery. The current literature provides conflicting data on this topic. The true association between pregnancy and thyroid nodules is unknown. Contemporary literature is ambiguous on this topic and more scientific studies are required to find the true association between pregnancy, the formation of thyroid nodules, and increase in the size or number of thyroid nodules.

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Transient cold nodule of the thyroid due to localized postpartum thyroiditis

Acta Endocrinologica ◽

10.1530/eje.0.1380562 ◽

1998 ◽

pp. 562-564 ◽

Cited By ~ 2

Author(s):

R Luboshitzky ◽

G Qupti ◽

A Ishai ◽

M Dharan

Keyword(s):

Thyroid Nodule ◽

Thyroid Function ◽

Needle Aspiration ◽

Thyroid Function Tests ◽

Thyroid Scintigraphy ◽

Postpartum Thyroiditis ◽

Normal Thyroid Function ◽

Function Tests ◽

Needle Aspiration Cytology ◽

Cold Nodule

A 27-year-old woman with no previous personal or family history of thyroid disease was referred to us for the evaluation of thyroid nodule, five months postpartum. Thyroid scintigraphy demonstrated a left cold nodule. Fine needle aspiration cytology of the nodule showed a mixture of colloid, follicular cells and lymphocytes, suggesting lymphocytic thyroiditis. Thyroid function tests were normal and thyroid autoantibodies were negative. After two months the thyroid nodule was not palpated and thyroid scintigraphy returned to normal. Thyroid function tests remained normal twelve months after delivery. These findings suggest that postpartum thyroiditis may present as a localized transient form and should be considered in the differential diagnosis of painless solitary nodule that appears postpartum.

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Effect of Early Referral to an Endocrinologist on Efficiency and Cost of Evaluation and Development of Treatment Plan in Patients with Thyroid Nodules

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jcem.83.11.5268 ◽

1998 ◽

Vol 83 (11) ◽

pp. 3803-3807 ◽

Cited By ~ 16

Author(s):

Robert Ortiz ◽

Kenneth H. Hupart ◽

Charles R. DeFesi ◽

Martin I. Surks

Keyword(s):

Thyroid Nodule ◽

Thyroid Function ◽

Thyroid Nodules ◽

Total Direct Cost ◽

Thyroid Function Tests ◽

Early Referral ◽

Diagnosis And Management ◽

Function Tests ◽

Radionuclide Uptake ◽

Unnecessary Testing

Radionuclide uptake and scan and sonogram, frequently ordered before referral to an endocrinologist, are expensive and poor predictors of thyroid nodule malignancy. We estimated costs of excessive imaging and other studies by reviewing the records of all patients (n = 70) referred to a single, consulting endocrinologist, for thyroid nodule evaluation in a 2-yr interval and subsequently, presenting only pertinent histories and results of physical examinations, thyroid function tests, and thyroid autoantibodies, to a second, reviewing endocrinologist (RE) who was blinded to diagnosis and management. Concordance in diagnosis and management between consulting endocrinologist and RE was 87.1% and 93.4%, respectively. Accuracy of diagnosis, loss of patient’s time (8.7 h, average), and cost of unnecessary testing, defined as tests not required by the RE for diagnosis and management according to published guidelines, were determined. Unnecessary testing included 153 physician’s office or diagnostic laboratory visits, 44 sets of thyroid function tests, 32 radionuclide uptake and scan, 39 thyroid sonograms, and 3 computed tomography scans. The total direct cost of unnecessary tests was estimated at $27,290 ($390/patient) in addition to costs of 30 unnecessary physician’s office visits. Only 2 of 8 surgical referrals required surgery, whereas 6 other patients required surgery, including 3 with papillary carcinoma. We conclude that early referral to an endocrinologist of patients with suspected thyroid nodules results in significant savings in cost of evaluation, patient’s time, and increased diagnostic precision. Six of the 8 patients referred for surgery before endocrine consultation had benign thyroid disease that did not require surgery. Six additional patients were referred to surgery, 3 of whom had papillary thyroid carcinoma. Early referral of patients with suspected thyroid nodules to an endocrinologist results in significant savings in both cost and patient’s time as well as increased precision of diagnosis.

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Goiter in Children

Pediatrics in Review ◽

10.1542/pir.5.9.259 ◽

1984 ◽

Vol 5 (9) ◽

pp. 259-272

Author(s):

Thomas P. Foley

Keyword(s):

Thyroid Gland ◽

Thyroid Nodule ◽

Thyroid Function ◽

Graves Disease ◽

Thyroid Function Tests ◽

Thyroid Antibodies ◽

Presumptive Diagnosis ◽

Function Tests ◽

Serum Tsh

The diagnostic evaluation of the patient with thyromegaly will be determined by the clinical history and an examination of the thyroid gland (Table 9). In most instances the diagnosis will not be in doubt, and only a few tests will be necessary. For example, the euthyroid adolescent female with an asymmetrically or symmetrically enlarged, firm thyroid gland has a presumptive diagnosis of CLT, and only tests of thyroid function (T4 and TSH) and thyroid antibodies may be needed for confirmation. Similarly, the patient with clinical symptoms and signs of hyperthyroidism, exophthalmus, and a diffusely enlarged, soft thyroid gland has a presumptive diagnosis of Graves disease. The necessary tests include only a measurement of T4, an estimate of free T4, and WBC and differential counts prior to the initiation of antithyroid drug therapy. [See table in the PDF file] In the absence of an obvious diagnosis, the clinician will select the specific diagnostic tests depending upon the examination of the thyroid gland. The cause of smooth, symmetrical, diffuse enlargement of the thyroid gland can be suspected with careful history for familial disease, history of exposure to goitrogens and goitrogenic drugs, and the determination of thyroid antibodies in serum. If the clinical history is suggestive of hyperthyroidism, the tests of thyroid function tests should include determination of serum T3 concentration; if the history is compatible with euthyroidism or hypothyroidism, thyroid function tests should include determination of serum TSH concentration for the presence of compensated primary hypothyroidism. If results of these tests are normal, no additional tests are necessary, and the patient should be reassured and seen again in six months. If the patient has a test that is negative for thyroid antibodies and an elevation of serum TSH concentration, a radioactive [123I]iodide uptake and perchlorate discharge test will be helpful in the diagnosis of familial dyshormonogenesis. The patient with constitutional symptoms of inflammatory disease, history of a recent upper tract respiratory infection, and a tender or nontender enlarged thyroid gland may have subacute thyroiditis; a low or absent uptake of radioiodine with high-normal or elevated T4 and T3 concentrations will be suggestive of that diagnosis. In patients with thyromegaly and mild symptoms of hyperthyroidism, a TRH test will help to discriminate hyperthyroxinemia secondary to increased or abnormal serum thyroxine binding proteins from early Graves disease, factitious hyperthyroidism, toxic thyroiditis, and TSH-mediated hyperthyroidism. The T3 suppression test is a definitive diagnostic test for early, mild Graves disease. The euthyroid patient with mild-to-moderate thyromegaly and tests that are negative for thyroid antibodies usually deserves no further diagnostic evaluation, but should be followed with a presumptive diagnosis of idiopathic goiter or mild CLT. On follow-up evaluation, initially at six-month intervals and subsequently at yearly intervals, the patient should have a clinical and biochemical assessment until thyromegaly regresses and the gland is normal in size and consistency. The patient with a nontender, firm, irregular enlargement of the thyroid gland usually has CLT. If results of thyroid function tests are normal and tests for thyroid antibodies are negative, the patient should be seen again in four to six months and serum thyroid antibody determinations again performed. Another test that may give abnormal results in patients with CLT is the perchlorate discharge test. The approach to the patient with the solitary thyroid nodule differs from that of the previously described clinical presentations. The most important studies for the patient with a thyroid nodule are those designed to determine the structure and consistency of the thyroid gland, namely, ultrasonography to distinguish between solid and cystic lesions, and the radionuclide scan to determine whether the nodule is functioning (hot) or nonfunctioning (cold). To assure that the thyroid nodule is not associated with a nonsurgical lesion such as Hashimoto thyroiditis, serum thyroid antibody determinations are important. As malignancy of the thyroid gland is usually not associated with abnormalities of thyroid function, it is important to perform laboratory tests to exclude hyperthyroidism (a serum T3 determination) and hypothyroidism (a serum TSH determination) at the time of initial evaluation. Additional tests are usually not necessary unless the patient had mild hyperthyroidism with an autonomously functioning nodule, in which case the T3 suppression test and TRH test are often useful; rarely, the TSH stimulation test is helpful in determing whether thyroid tissue throughout the remainder of the gland is suppressed. A solitary, solid, nonfunctioning (cold) nodule requires excisional biopsy.

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Correlation Between Cytologic Results and Thyroid Autoantibodies, Calcitonin, and Thyroid Function Tests in Patients with Thyroid Nodules

International Journal of Scientific Research and Management ◽

10.18535/ijsrm/v6i2.mp01 ◽

2018 ◽

Vol 6 (02) ◽

Author(s):

Pinar Karakaya ◽

Bahar Ozdemir ◽

Bulent Yaprak ◽

Meral Mert

Keyword(s):

Thyroid Function ◽

Thyroid Nodules ◽

Needle Aspiration ◽

Thyroid Function Tests ◽

Pathologic Evaluation ◽

Function Tests ◽

Multiple Category ◽

Bethesda Classification ◽

Range Interval ◽

Undetermined Significance

Abstract Background: Fine needle aspiration biopsy (FNAB) is currently a widely accepted screening procedure in diagnosis of thyroid nodules, there has been confusion related to diagnostic terminology in the assessment of samples. This confusion has been caused by multiple category names, descriptive reports without assigning to a category, and different terminologies used for surgical pathology. We aimed to evaluate correlations between US characteristics, cytologic results of FNAB, and thyroid antibodies, calcitonin, and thyroid function tests in patients presented with thyroid nodules, and to contribute in diagnosis, treatment, and patient follow-up. Methods: A total of 1639 patients with thyroid nodules who applied to outpatient clinic of endocrinology between dates April and May 2017, had FNAB under US guideline, and their pathologic evaluation was performed according to Bethesda classification. Serological and hormonal tests were also performed for each patient. Results: The mean age of study group was 50 (range interval= 14-90) years. The median of node-diameter1 was 17.5 (range=1-51) mm, and median of node-diameter2 was 12 (range=8-33) mm. Of US characteristics, echogenicity, microcalcification, irregular borders, and solitary nodules were determined in 4.4%, 54%, 71.2%, and 86.6% of cohort respectively. Elevated anti-TPO was determined in 64.6%. Cytologic readings were reported as 15.8% nondiagnostic, 53.8% atypia of undetermined significance/follicular lesion of undetermined significance, 28.8% benign, 0.4% suspicious for follicular nodule, and 1.2% malign. Conclusion: Measurement of thyroid autoantiboides, calcitonin, and thyroid function tests have good correlations with Bethesda classification in patients with thyroid nodules.

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Sonographic Echo-pattern of the Thyroid Gland among the Non-nodular Goitrous Patients Having Abnormal thyrotropin Level at their First Diagnosis

Bangladesh Journal of Nuclear Medicine ◽

10.3329/bjnm.v18i2.35235 ◽

2018 ◽

Vol 18 (2) ◽

pp. 152-155

Author(s):

Nasrin Begum ◽

Kabiruzzaman Shah ◽

Parvez Ahmed ◽

Mosharruf Hossain ◽

Shariful Islam Chowdhury ◽

...

Keyword(s):

Thyroid Gland ◽

Thyroid Function ◽

Nodular Goiter ◽

Sampling Technique ◽

Needle Aspiration ◽

Thyroid Function Tests ◽

Normal Range ◽

Management Algorithm ◽

Function Tests ◽

Thyrotropin Level

Objective: This study was done to observe the high resolution sonographic echo-pattern of the thyroid gland among the non-nodular goitrous patients having abnormal thyrotropin (TSH) level at their first diagnosis.Method: This study was conducted at the Institute of Nuclear medicine and Allied Sciences, Rajshahi, Bangladesh during the period between 1st January, 2014 and 31st March, 2015. The goitrous patients are referred at this Institute by the clinicians for radionuclide thyroid scan, HRUS of thyroid gland and thyroid function tests. Under the basis of convenient sampling technique, 62 patients are included as sample. Their age, gender, HRUS echo-patterns of goiter and thyrotropin levels are recorded and analyzed with statistical software IBM SPSS v. 16.Results: Among the total enrolled patients (n=62), 57 (91.9 %) were female and five (8.1 %) were male. Mean (± SD) age was 28 ± 11.85 years (range=8 to 69 years). Regarding thyrotropin level among the sample patients (n=62), 53 (85.5 %) had above normal range and 9 (14.5 %) had below normal range. In relation to sonographic echo-pattern of the non-nodular goitrous patients (n=62), 43 (69.4 %) had hypoechoic feature, 15 (24.2 %) had non-homogenous feature and four (6.5 %) had both hypoechoic and non-homogenous feature. Among the 43 goitrous patients with hypoechoic feature, 38 had thyrotropin above normal range and five had below normal range; among the 15 goitrous patients with non-homogenous feature, 12 had thyrotropin above normal range and three had below normal range and among the four goitrous patients with both hypoechoic and non-homogenous feature, three had thyrotropin above normal range and one had below normal range.Conclusion: The results of this study will be helpful in the relevant prospective studies which will be concerned with developing non-nodular goiter management algorithm, in addition to the role of other parameters like thyroid function tests especially thyrotropin level, circulating thyroid autoantibodies detection and fine needle aspiration biopsy (FNAB) cytology findings.Bangladesh J. Nuclear Med. 18(2): 152-155, July 2015

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Enlarged Thyroid Gland with Normal Thyroid Function Tests

Baylor University Medical Center Proceedings ◽

10.1080/08998280.2008.11928388 ◽

2008 ◽

Vol 21 (2) ◽

pp. 179-182

Author(s):

Carol F. Adair ◽

John T. Preskitt ◽

Kristin L. Joyner ◽

Robin W. Dobson

Keyword(s):

Thyroid Gland ◽

Thyroid Function ◽

Thyroid Function Tests ◽

Normal Thyroid ◽

Normal Thyroid Function ◽

Function Tests

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Thyroid Abscess Initially Presenting as Destructive Thyroiditis With Subsequent Hypothyroidism

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1964 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A961-A961

Author(s):

Ahl Jeffrey Caseja ◽

Richard L Wang ◽

Samer Nakhle

Keyword(s):

Thyroid Gland ◽

Thyroid Function ◽

Fluid Collection ◽

Neck Mass ◽

Vascular Supply ◽

Thyroid Function Tests ◽

Ct Guided ◽

Hormone Synthesis ◽

Function Tests ◽

Thyroid Abscess

Abstract Introduction: Due to its rich vascular supply and high iodine content infection of the thyroid gland is rare and is uncommonly associated with hyperthyroidism. We report a case of a thyroid abscess presenting with hyperthyroidism with subsequent hypothyroidism in an immunocompetent patient. Clinical Case: A 34-year old female with no past medical history presented with an enlarging neck mass associated with worsening, non-radiating throat pain of three-week duration associated with dysphagia. She reports 15-lb weight loss and palpitations. On presentation vital signs were within normal range. Physical examination revealed a diffusely tender anterior neck mass. Her thyroid function tests revealed TSH 0.01 uIU/mL (0.358-3.74), FT4 2.4 ng/dL (0.76-1.46), TSI <0.10 IU/L (0.00-0.55), TPO 12 IU/mL (0-34). Laboratory workup was also significant for leukocytosis, thrombocytosis, and hyponatremia. Thyroid ultrasound revealed a large, irregularly shaped, multiloculated fluid collection involving both lobes measuring 6.4 x 4.8 x 2.0 cm. She was started on Vancomycin and Ampicillin/Sulbactam, Metoprolol, and Methimazole. Needle aspiration of 30 cc of purulent material was performed with culture showing a heavy growth of streptococcus constellatus sensitive to penicillin. After a 4-day inpatient stay, she was discharged with Amoxicillin/Clauvanate as well as Methimazole 10mg BID. Ten days after being discharged, the patient again presented to the emergency department with complaint that the neck mass had increased in size. CT neck showed a 5.1 x 2.8 x 0.8 cm lobulated fluid collection. CT-guided drainage was performed, cytology and wound culture were found to be unremarkable. Thyroid function tests revealed she was hypothyroid with TSH 31.157 uIU/mL and FT4 of 0.72 ng/dL. Upon discharge, Methimazole was discontinued and she was started on Levothyroxine 75 mcg daily. Due to failure of prior antibiotics, she received a 14-day course of IV Ceftriaxone. Outpatient follow-up eight weeks later showed she was euthyroid on Levothyroxine 75 mcg with ultrasound revealing small thyroid gland with resolution of the abscess. Conclusion: Hyperthyroidism in the setting thyroid abscess is secondary to destructive thyroiditis. As there is no increase in thyroid hormone synthesis, there is no role for treatment with antithyroid medication. Symptomatic control with beta-blocker, surgical drainage, and IV antibiotics are recommended for cases of thyroid abscesses. If infection persists or extensive necrosis develops, thyroidectomy may be indicated. Hypothyroidism can be a consequence of destructive thyroiditis as was seen in this patient.

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Radioiodine in the Diagnosis and Therapy of Solitary Hyperfunctioning Thyroid Nodules

Nuklearmedizin ◽

10.1055/s-0037-1621361 ◽

1968 ◽

Vol 07 (01) ◽

pp. 82-90

Author(s):

A. Y. Al Hindawi ◽

Th. N. Al-Hiti ◽

W. I. Baba

Keyword(s):

Thyroid Gland ◽

Thyroid Nodule ◽

Thyroid Function ◽

Thyroid Nodules ◽

Clinical Presentation ◽

Radioiodine Therapy ◽

Thyroid Tissue ◽

Toxic Adenoma ◽

Diagnosis And Therapy ◽

High Doses

SummaryThe clinical presentation, the incidence, and the results of radioiodine tests in 80 patients with hyperfunctioning thyroid nodule confirmed by scanning are presented. 52 patients had toxic adenoma and 28 were euthyroid.The value of different radioiodine tests of thyroid function in confirming the diagnosis is discussed.The topographical changes in both hyperfunctioning nodule and suppressed tissue of the thyroid gland following exogenous TSH and radioiodine therapy showed refunctioning of suppressed thyroid tissue.Relatively high doses of radioiodine were required to treat toxic adenoma of the thyroid gland.

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HYPOTHYROIDISM AND GOITER IN A YOUNG MALE WITH SUSPECTED DIETARY IODINE DEFICIENCY FOLLOWED BY THYROTOXICOSIS AFTER IODINE SUPPLEMENTATION

AACE Clinical Case Reports ◽

10.4158/accr-2019-0180 ◽

2020 ◽

Vol 6 (1) ◽

pp. e19-e22

Author(s):

Itivrita Goyal ◽

Manu Raj Pandey ◽

Rajeev Sharma

Keyword(s):

Thyroid Gland ◽

Thyroid Function ◽

Iodine Deficiency ◽

Urinary Iodine ◽

Young Male ◽

Free Thyroxine ◽

Thyroid Function Tests ◽

Normal Range ◽

Iodine Supplementation ◽

Function Tests

Objective: Iodine deficiency disorders (IDDs) remain a major public health concern in most parts of the world but are extremely rare in North America. We describe a case of goiter in a young male with dietary history and findings suggestive of IDD. Methods: Laboratory and imaging procedures including thyroid function tests, autoantibodies, urine iodine, thyroid ultrasound, and radioactive iodine (RAI) uptake scan were performed. Results: On initial presentation, thyroid-stimulating hormone (TSH) was 24.4 mIU/L (normal range is 0.4 to 5.0 mIU/L), free thyroxine was <0.4 ng/dL (normal range is 0.8 to 1.8 ng/dL), and thyroid peroxidase antibody was positive at 43 IU/mL (normal range is <35 IU/mL). He reported consuming strawberries and peanut butter sandwiches with no intake of dairy or seafood due to gastrointestinal issues (abdominal pain, bloating, and nausea). Physical exam revealed a diffusely enlarged, palpable thyroid gland (grade II goiter). Ultrasound of the neck showed an enlarged thyroid gland with no nodules. RAI uptake scan showed diffuse increased uptake (91%). Given his poor diet, a 24-hour urinary iodine excretion test was ordered which was suggestive of very low iodine intake. He was started on multivitamins with 150 μg of iodine daily. On follow up, clinical exam showed grade I goiter and TSH had normalized to 0.7 mIU/L and free thyroxine was 1.2 ng/dL. He continued on iodine supplementation and tolerated iodine-rich foods. Six months later, thyroid function tests showed hyperthyroidism with TSH of <0.002 ng/dL and free thyroxine was elevated to 2.8 ng/dL. Iodine supplements were stopped. Conclusion: Hypothyroidism and goiter due to IDD should be suspected in the setting of poor dietary intake. IDDs can be rapidly diagnosed in a patient on a restricted diet with multiple urinary iodine determinations and RAI study. Regular thyroid labs should be done to monitor for hyperthyroidism that can develop after iodine supplementation.

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