A 52-year-old woman comes to the office due to fatigue and mild weight loss. For the last several weeks, she has also experienced hot flashes, heat intolerance, and trouble sleeping. The patient has had no tremors, palpitations, neck pain, proximal weakness, eye discomfort, diplopia, or swelling. Her medical history is notable for hypertension treated with metoprolol and hydrochlorothiazide. Family history is positive for hypertension and osteoporosis in her mother. The patient does not use tobacco or alcohol. She experienced natural menopause at age 50.
Vital signs are normal. Ocular examination shows mild lid lag without proptosis. Neck examination reveals a 2.5-cm nodule in the right lobe of the thyroid gland without surrounding lymphadenopathy. There are no tremors or pretibial myxedema. The remainder of the examination is normal.
Laboratory results are as follows:
Thyroid ultrasound shows a 2.5-cm solitary thyroid nodule in the right lobe. Radioactive iodine uptake scan (shown in the image) at 24 hours is 30% (normal: 10%-30%), predominantly in the nodule with minimal surrounding uptake.

Beta blocker therapy is initiated to reduce the patient's symptoms. Which of the following additional interventions is the most appropriate management for this patient's condition?

Question

A 52-year-old woman comes to the office due to fatigue and mild weight loss.  For the last several weeks, she has also experienced hot flashes, heat intolerance, and trouble sleeping.  The patient has had no tremors, palpitations, neck pain, proximal weakness, eye discomfort, diplopia, or swelling.  Her medical history is notable for hypertension treated with metoprolol and hydrochlorothiazide.  Family history is positive for hypertension and osteoporosis in her mother.  The patient does not use tobacco or alcohol.  She experienced natural menopause at age 50.
Vital signs are normal.  Ocular examination shows mild lid lag without proptosis.  Neck examination reveals a 2.5-cm nodule in the right lobe of the thyroid gland without surrounding lymphadenopathy.  There are no tremors or pretibial myxedema.  The remainder of the examination is normal.
Laboratory results are as follows:
 Thyroid ultrasound shows a 2.5-cm solitary thyroid nodule in the right lobe.  Radioactive iodine uptake scan (shown in the image) at 24 hours is 30% (normal: 10%-30%), predominantly in the nodule with minimal surrounding uptake.

Beta blocker therapy is initiated to reduce the patient's symptoms.  Which of the following additional interventions is the most appropriate management for this patient's condition?

Quizplus · Accepted Answer

This patient has hyperthyroidism associated with a large thyroid nodule. The initial evaluation of a thyroid nodule includes a serum TSH assay and thyroid ultrasound. Patients with benign ultrasound findings and suppressed TSH should then undergo radioactive iodine uptake (RAIU) scintigraphy to differentiate Graves disease from a hyperfunctioning toxic adenoma. Patients with a toxic adenoma typically have mildly elevated or high-normal RAIU concentrated within the nodule, as seen in this patient. Graves disease causes markedly elevated uptake throughout the gland. Patients with toxic adenoma or multinodular goiter who have overt hyperthyroidism (low TSH, increased T4) should have definitive treatment with radioactive iodine ablation or surgical thyroidectomy, rather than only symptomatic management (Choice E). Unlike Graves disease, in which radioiodine ablation leads to postablative hypothyroidism, the radioactive iodine in nodular thyroid disease is taken up primarily in the abnormal tissue, with little damage to the surrounding healthy tissue. Following treatment, most patients are euthyroid. Surgery is considered for patients with large goiters, coexisting malignancy, or primary hyperparathyroidism, as well as those who need rapid correction of hyperthyroidism. (Choice A) Fine-needle aspiration is indicated for hypofunctioning ("cold") nodules and nodules with ultrasound findings suspicious for malignancy (eg, microcalcifications, increased vascularity, infiltrative margins), particularly if ≥1 cm. Fine-needle aspiration is not recommended for "hot" nodules as they are rarely malignant. (Choice B) Thionamides (eg, methimazole, propylthiouracil) can decrease thyroid hormone production in preparation for radioiodine ablation or surgery. They are also used as primary therapy for patients with Graves disease who have mild hyperthyroidism and small goiters. However, chronic use in toxic nodular disease is generally recommended only for patients who are poor surgical candidates or decline definitive therapy. (Choice C) Prednisone inhibits peripheral conversion of T4 to T3 and can reduce hormone secretion in Graves disease, severe hyperthyroidism, and thyroid storm. However, it is not indicated for toxic adenoma or multinodular goiter. Educational objective: The initial evaluation of a thyroid nodule includes a serum TSH and thyroid ultrasound. Patients with benign ultrasound findings and suppressed TSH should undergo radioactive iodine scintigraphy. Toxic thyroid adenoma or multinodular goiter with hyperthyroidism is treated with radioactive iodine ablation or surgical thyroidectomy. __________ References: Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. (http://www.ncbi.nlm.nih.gov/pubmed/21510801) Hyperthyroidism: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/26926973)

A 52-Year-Old Woman Comes to the Office Due to Fatigue