It is a disease that is usually seen in elderly female patients. It often progresses with high thyroid hormones and is one of the most common causes of hyperthyroidism. However, it can be said that pre-existing nodules in these patients progress without causing an increase in thyroid hormones and change over time. In these patients, it is seen that the nodules show an autonomous course and become activated spontaneously and increase thyroid hormone levels. These nodules may be single or multiple. The increase in thyroid hormone levels can vary from controllable levels to severe thyrotoxicosis levels.
Any stimulus can make the thyroid glands grow and develop nodules. Over time, chronic stimulus continuity can cause enlargement of the thyroid gland and its transformation into an autonomous hormone-secreting tissue. It has been found that genetic stimuli are more common in patients with familial thyroid disease. In addition, diseases that cause high TSH secretion from the pituitary gland can also be a chronic thyroid stimulant. However, stress, smoking, some drugs and other stimulating factors can be effective.
Nutrition with low iodine levels as external stimuli causes the iodine required for thyroid hormones to not be taken, the production of thyroid hormone becomes more difficult, and the thyroid glands work harder to produce enough hormone. In chronic conditions, these nodules may develop and turn into autonomous nodules over time.
Non-toxic nodular goiter is usually seen at younger ages, while toxic multinodular goiter is usually seen in older ages due to the transformation of non-toxic nodules. Toxic multinodular goiter creates a thyroid appearance with mostly active nodules in the thyroid gland, sometimes with inactive nodules, bleeding from place to place, and fibrosis in the follicles.
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Symptoms of toxic multinodular goiter:
In these patients, complaints of tachycardia, heart failure, arrhythmia, weight loss, irritability, weakness, tremor and sweating are more common. The thyroid can sometimes be palpably enlarged. Patients may also state that they have less tolerance to heat and develop more frequent defecation habits. Menstrual irregularity may be frequent in women.
These patients may develop painful conditions or bone fractures due to muscle damage. Children may experience bedwetting at night. Patients with excessive enlargement of the nodules in the thyroid gland may experience hoarseness, a feeling of being stuck in the neck, difficulty in swallowing or shortness of breath.
In these patients, a more reddened skin, sweaty and thin skin can be seen due to hyperthyroidism. Even nervous and psychological disorders can be seen in some patients.
Diagnosis of toxic multinodular goiter:
As with all thyroid disease suspicions, thyroid hormones are primarily examined in these patients. TSH, T3 and T4 levels are evaluated. In these patients, TSH levels are generally decreased and suppressed, while T3 and T4 levels are increased. Liver functions and other blood parameters may also be evaluated. Antithyroid peroxidase (anti-TPO) antibodies and antithyroglobulin antibodies may also be examined.
It may be useful to examine the thyroid gland and evaluate nodules with thyroid ultrasonography in patients who are thought to need further evaluation with laboratory tests. In addition, thyroid blood flow can be examined with color Doppler.
Since there are many diseases with hyperthyroidism, thyroid scintigraphy may be required to differentiate toxic multinodular goiter. Fine-needle aspiration biopsy can also be useful to distinguish which nodules are active or inactive. With fine needle aspiration biopsy, detailed tissue examination is also possible.
In patients with excessive thyroid gland enlargement, thyroid borders, structure and condition of surrounding tissues can sometimes be examined by computed tomography or magnetic resonance imaging. In fact, performing laryngoscopy and examining the condition of the vocal cords in patients with hoarseness will contribute to the evaluations.
Toxic multinodular goiter (Plummer’s disease) treatment:
Although it is possible to monitor patients without clinical findings, the treatment of toxic multinodular goiter is surgery. The fact that these patients are generally elderly and have comorbid paternal diseases complicates the treatment. Surgical treatment can provide faster recovery. Depending on the condition of the disease, total, near-total or partial thyroidectomy can be performed. There is a small chance of recurrence after partial thyroidectomy.
Surgical treatment may have complications such as hoarseness or loss of voice, hypothyroidism, hypoparathyroidism, post-operative bleeding or infections, and tracheostomy.
Radioactive iodine ablation can be performed in addition to surgery in patients with toxic multinodular goiter. It is a treatment that can be applied except for pregnant women. However, radioactive iodine treatment may not fully heal the disease and may delay the process. There is also the possibility of developing cancer from radioactive iodine. In addition, hypothyroidism or hyperthyroidism severe enough to thyroid storm, congestive heart failure and atrial fibrillation may also be possible complications of radioactive iodine therapy.
During the waiting period until surgical or radioactive iodine ablation treatment is performed, patients can also use drugs such as propylthiouracil or methimazole. Propylthiouracil is preferred in pregnant women. It seems that methimazole treatment is safer in patients who are considered for long-term drug therapy, except for pregnancy.
In rare cases, ethanol ablation therapy may be considered in patients who are not amenable to surgical treatment and whose cancer has been clarified. Although there is a regression in symptoms with a few sessions of application, it may not provide permanent treatment.
Patients who do not show any symptoms may not need treatment. Follow-up patients can be re-evaluated with surgery or other treatments if necessary.
Toxic multinodular goiter carries the complications of hyperthyroidism due to hyperactivity of the thyroid gland. Patients may develop tachycardia, atrial fibrillation and heart failure. Concomitant diseases such as COPD can make the process worse. In addition, bone loss, osteoporosis and fractures can be seen in these patients.
Toxic multinodular goiter may be accompanied by malignancies in some cases. Although it is rare, thyroid malignancies should be investigated in these patients.