Nodular Hyperthyroidism

Patient Presentation:
S.H., a 17-year-old female presents to her physician’s office complaining of recently having found a small, palpable lump in her anterior neck. The patient also states for the past few months she has experienced feelings of her heart racing, increased sensitivity to heat, heavy sweating, and high anxiety levels that have interfered with her daily life. S.H. reports family history of paternal aunt with Graves Disease and a 23 year old female and 24 year old male siblings each with multiple benign thyroid nodules.

Differential List:
Graves’ Disease, follicular thyroid carcinoma, hyperfunctioning thyroid nodule

Diagnosis:
After ultrasound confirmed the presence of a single mass along the thyroid gland, patient underwent fine needle aspiration biopsy to determine whether the mass was benign or showed changes consistent with malignancy. Results determined the mass was benign and the patient is diagnosed with a thyroid nodule. Laboratory tests drawn show T3, T4 are elevated and TSH is low (T4 total thyroxine: 14mcg/dL, T3 total: 250 ng/dL, TSH: 0.19mIU/L)

S.H. also had an Iodine Uptake Scan performed. The patient was given I-123 and her thyroid uptake of the iodine was elevated. Her thyroid scan showed the nodule had a high concentration of the iodine uptake, signaling that her nodule was likely responsible for her elevated T3 and T4 levels.

Treatment:
For her treatment, S.H. took oral I-131 and was on isolation for 72 hours in her home. The radioactive iodine targeted the nodule, which was responsible for overproducing thyroid hormone. The treatment intends for the nodule to shrink, thus reducing the severity of her signs and symptoms. Other routes of treatment that are often considered for hyperthyroidism include possible removal of the thyroid gland and anti-thyroid medications.

Outcome:
Eight weeks later, S.H. had her thyroid re-tested to ensure her thyroid levels were within normal range and to evaluate success of the treatment. Typically it can take several months for symptoms of hyperthyroidism to diminish. There is also a risk the patient could develop hypothyroidism from the effects of the radioactive iodine, so having her thyroid levels checked again is an important follow-up step for patients who are treated with radioactive iodine.
Case created by Shannan Henry, 2011.