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A 55-year-old woman presented with a several-month history of fatigue and weight gain. She reported that she felt puffy and swollen. She had difficulty buttoning the top button of her blouse because her neck was so large, but she reported no neck pain. Review of systems was positive for constipation, dry skin, and cold intolerance. On physical examination, a large goiter was found (Figure 226-1). Laboratory testing revealed an elevated thyroid-stimulating hormone (TSH) and a low free thyroxine (FT4) level confirming hypothyroidism. The patient was started on levothyroxine.

Figure 226-1

Goiter that extends approximately 2 cm forward when viewed from the patient's side. (Courtesy of Dan Stulberg, MD.)

  • Goiter is a spectrum of changes in the thyroid gland ranging from diffuse enlargement to nodular enlargement depending on the cause. In the United States, the most common etiology of goiter with normal thyroid function or transient dysfunction is thyroiditis.
  • Hypothyroidism is a condition caused by lack of thyroid hormone and usually develops as a result of thyroid failure from intrinsic thyroid disease. The most common cause of goitrous hypothyroidism is chronic lymphocytic (Hashimoto) thyroiditis.
  • Subclinical thyroid disease refers to a patient with no or minimal thyroid-related symptoms but abnormal laboratory values (elevated TSH and thyroxine level within the normal range).

  • Worldwide, goiter is the most common endocrine disorder with rates of 4% to 15% in areas of adequate iodine intake and more than 90% where there is iodine deficiency.1 Endemic goiter is defined as goiter that affects more than 5% of the population (Figures 226-2 and 226-3).
  • Most goiters are not associated with thyroid dysfunction.
  • The prevalence of goitrous hypothyroidism varies from 0.7% to 4% of the population.
  • Subclinical hypothyroidism is present in 3% to 10% of population groups and in 10% to 18% of elderly persons.2,3
  • The female-to-male ratio of goiter is 3:1, and 6:1 for goitrous hypothyroidism.
  • The annual incidence of autoimmune hypothyroidism is 4 in 1000 women and 1 in 1000 men, with a mean age at diagnosis of 60 years.4

Figure 226-2

Massive goiter in an Ethiopian woman who lives in an endemic area for goiters. Many adults have large goiters in Ethiopia where there is little iodine in their diets. (Courtesy of Richard P. Usatine, MD.)

Figure 226-3

Goiter developing in a 12-year-old girl in an endemic area for goiters. (Courtesy of Richard P. Usatine, MD.)

Contributing factors for goiter are:

  • Iodine deficiency or excess (Figures 226-2 and 226-3).
  • TSH stimulation.
  • Drugs, including lithium, amiodarone, and α-interferon.
  • Autoimmunity/heredity.

Hypothyroidism may be caused by disease of the thyroid gland itself ...

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