Thyroid

The thyroid gland produces, stores, and secretes thyroxine (T4) and triiodothyronine (T3) through a negative feedback process involving the hypothalamus and pituitary gland. Thyroid dysfunction can result when any part of this process is affected, and is usually characterized by the presence of high or low levels of thyroid-stimulating hormone (TSH, secreted by the pituitary gland) and free thyroid hormones.

Causes of thyroid disorders include: Autoimmunity (e.g., Graves disease), infections (e.g., postviral inflammation), other systemic medical conditions, medications (e.g., lithium, amiodarone), nutritional excesses or deficiencies (e.g., of iodine), tumors (thyroid, or rarely pituitary), trauma, or pregnancy.

Related conditions: Thyroid function testing: If screening for thyroid dysfunction in the absence of hypothalamic or pituitary pathology is undertaken, serum TSH assay is usually the initial laboratory test. Suppressed or elevated TSH confirms presence of thyroid dysfunction but not its cause.

Diagnosis of hyperthyroidism is usually confirmed with suppressed TSH and high serum levels of free T4 and/or free T3. If screening for hypothyroidism (primary) is undertaken, this is generally done with detection of an elevated TSH. Further testing (e.g, radioactive iodine uptake) may be used subsequently to clarify etiologies in some cases.

Graves disease: Graves disease is an autoimmune thyroid disease and is the most common form of hyperthyroidism in most areas of the world. Hyperthyroidism is caused by stimulatory TSH receptor antibodies.

Toxic multinodular goiter: A toxic multinodular goiter (MNG) contains multiple autonomously functioning nodules, resulting in hyperthyroidism that generally does not remit spontaneously. Nodules function independently of TSH and are almost always benign. However, nonfunctioning thyroid nodules in the same goiter may be malignant. Worldwide, iodine deficiency is the most common cause of nodular goiter.

Toxic thyroid adenoma: An autonomously functioning thyroid nodule that causes hyperthyroidism and, generally, does not remit. Typically a single large nodule (almost always benign). It is most common in younger patients (20-40 years). Iodine deficiency is a strong risk factor (and is also the most common cause of nodular goiter).

Painless lymphocytic thyroiditis: Autoimmune-mediated inflammation of the thyroid gland with release of thyroid hormone (destructive thyroiditis), resulting in transient hyperthyroidism, frequently followed by a hypothyroid phase before recovery of normal thyroid function. Permanent hypothyroidism may occur. Considered by many to be a variant of chronic lymphocytic (Hashimoto) thyroiditis.

Subacute granulomatous thyroiditis: Inflammation of the thyroid characterized by a triphasic course of transient thyrotoxicosis, followed by hypothyroidism, followed by return to euthyroidism. The initial thyrotoxic phase is associated with thyroid pain, high serum thyroid hormone levels with a low radioiodine uptake, elevated ESR, elevated CRP, and a systemic illness similar to influenza, with fever, myalgia, and malaise.

Primary hypothyroidism: Clinical state resulting from underproduction of T4 and T3. Low free T4 with an elevated TSH is diagnostic of primary hypothyroidism. Autoimmune thyroiditis (Hashimoto disease) is the most common cause of primary hypothyroidism. Secondary/central hypothyroidism is caused by pituitary or hypothalamic dysfunction.

Central hypothyroidism: The result of anterior pituitary or hypothalamic dysfunction. Etiology may be congenital, neoplastic, inflammatory, infiltrative (e.g., tuberculosis, syphilis, fungal infections, toxoplasmosis, sarcoidosis, hemochromatosis, histiocytosis), traumatic, or iatrogenic. Pituitary mass lesions, especially pituitary adenomas, are the most common cause.

Thyroid cancer: Most commonly presents as an asymptomatic thyroid nodule in a woman in her 30s or 40s. The nodule might be found on physical examination or incidentally on neck ultrasound or CT. Treatment of the most common types (papillary or follicular) generally involves surgery, followed by radioactive iodine ablation and TSH suppression.

Evaluation of thyroid mass/enlargement Thyroid parenchymal expansion can result from diffuse enlargement or infiltration of the thyroid gland, or from the presence of one or more thyroid nodules.