Long standing goiter with mild hypothyroidism. BACK
AFM is a 27-year-old married female, born in the northeast region of Brazil.
The patient was admitted to the University Hospital with a history of goiter since school age (8-9 years old). The local doctor confirmed thyroid enlargement but did not prescribed any medication. After her second child was born (1999) she noticed dry skin, constipation, loss of hair and amenorrhea. Because of lab tests indicating hypothyroidism she was started on L-T4 (100 mcg q.d. and subsequently to 150 mcg q.d.). During her fourth and last pregnancy (2005) she stopped L-T4 spontaneously.. She had four uneventful pregnancies and all four children had normal Neo Natal Thyroid Screening Program tests. A sister was operated on a voluminous goiter and three of her siblings have goiter (not examined). The parents are first cousins
At physical examination a smooth, elastic goiter was palpable (about 80 g), with two nodules (about 2 cm), felt in each of the lobes Height 162 cm, Weight 58.1 kg, BMI 22.1 kg/m².
A chemical profile was unremarkable. Urinary iodine excretion was 184 µg I/L (normal 100 – 250 µg / IL) Thyroid function tests, thyroid auto-antibodies and serum TG are shown below (Table 1).
Table 1: Thyroid Function tests, antibodies and TG
|
|
May 01 |
Feb 02 |
April 06 |
March 06 |
June 06 |
Normal range |
|
Serum TSH
Free T4 Total T4 Total T3 |
4.15 0.5 6.4 231 treatment |
5.21 0.7 5.0 161 irregular |
L-T4 100 µg q.d. Started |
2.01 0.8 4.8 130 |
1.36 0.6 3.5 108 |
0.4 – 4.5 µU/mL 0.7 – 1.7 ng/dL 4.5– 12.0 µg/dL 80 – 180 ng/dL |
|
Serum TG Anti TPO Anti TG |
- Neg Neg |
- - - |
4.2 Neg Neg |
3.5 - |
0.5 –30.0 ng/mL < 35 U/mL <40 U/mL |
Thyroid echography revealed the presence of multiple nodules, predominantly solid and hyperechoic. The largest nodule is located in the upper part of the right lobe and measured 41 X 42 X 28 mm. Volume of the right lobe 49 mL, left lobe 31 mL, Isthmus 8.4 mL. Total volume 84.4 mL. The largest nodule was submitted to FNAB and the result was: Follicular proliferation (indeterminate). Thyroid RAI uptake was 61% (2h) and 82% (24h) with a multinodular goiter pattern of iodine accumulation. A perchlorate discharge test was negative.
What other studies you wish to obtain at his point?
FNAB of other nodules
MRI of the pituitary
Thyroid function tests and TG in her siblings.