Clinical scenario :
A 52-year-old woman with known past medical history of goiter presented to the emergency department with a rapidly growing goiter and shortness of breath of 5 days duration . The shortness of breath was positional, mainly when lying down without any history of chest pain, lower extremity edema, or fever.
The neck swelling had started 18 years ago and was progressively and slowly increasing in size .
She reported long- standing history of worsening loud snoring, fatigue, and excessive daytime sleepiness. She denied any history of palpitation, sweating, weight loss/gain or diarrhea. Otherwise, her past medical/surgical history was non-significant. She denied any allergy to medications.
Examination :
She was conscious oriented and had stable vitals .Her physical examination revealed a non-tender enlarged goiter with negative Pemberton’s sign and no visible dilated vein, facial edema, or proptosis. Her systemic examination was normal
Course in the hospital:
Keeping in view her obstructive symptoms she was planned for surgical removal of this large goiter. Her hemoglobin levels were normal .She had normal tests on Kidney and Liver functions . The thyroid ultrasound, showed a multi-nodular goiter with retro-sternal extension with 2 right thyroid nodules, the largest measuring 6x4x3 cm and 1 left thyroid nodule measuring 5×4×4 cm.
The thyroid functions T3 of 6.44 (normal 3.1–6.8), negative thyroid perox- idase and thyroglobulin antibody.
Levothyroxine 25 mcg was discontinued which she had been using intermittently (Table.1) and was started on oral Tab Dexamethasone 8mg 8hrly . Her shortness of breath improved with the dexamethasone but there were no changes in her snoring or fatigue.
On hospital day 5, she underwent a CT scan of the neck with contrast, which showed both thyroid lobes were enlarged, with the right lobe measuring 10×6.5×5 cm and left lobe measuring 12.5×7.5×6.5 cm. The gland reached the sub- mandibular region, with left lobe compression and shifting the oropharynx and the trachea to the right side with both lobes displaced.
After CT Scan her thyroid function tests showed features of Hyperthyroidism induced by contrast. This phenomenon of thyrotoxicosis precipitated by Iodine in the contrast is called Jod-Basedow phenomenon
She had refractory hyperthyroidism despite being on a high dose of carbimazole for 3 weeks, propranolol and high-dose dexamethasone.
She was then started on oral Tab Cholestyramine 4g twice daily and dexamethasone was tapered. She was carefully monitored and on hospital day 43, she underwent total thyroidectomy .The final histopathology report revealed a multi-nodular goiter with no malignancy.
On hospital day 50, she was discharged home in stable condition with resolution of the shortness of breath and improvement of the snoring without any hoarseness of the voice post-operatively.
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Fig Hospital course of the Patient .Addition of Cholestyramine lowered thyroid hormones to normal
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Teaching message ;
1.Iodine in contrast agents can induce Jod Basdow phenomenon and release of excessive thyroid harmones causing thyrotoxicosis.
2. After stepping up various antithyroid medications for thyrotoxiosis Clolestyramine can be used to treat resistant hyperthyroidism
Further reading click the link : Radio contrast induced thyroid dysfunction
Clinical case contributed by :
Dr Khaled Alswat
Consultant Endocrinologist
Vice Dean Clinical affairs
College of Medicine Taif university
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