Goitre

Goitre

Diffuse hyperplasia of the thyroid
Classification and external resources
Specialty Endocrinology
ICD-10 E01-E05
ICD-9-CM 240.9
DiseasesDB 5332
MedlinePlus 001178
MeSH D006042

A goitre (from the Latin gutteria, struma) is a swelling of the neck or larynx resulting from enlargement of the thyroid gland (thyromegaly), associated with a thyroid gland that is not functioning properly.

Worldwide, over 90.54% cases of goitre are caused by iodine deficiency.[1]

Signs and symptoms

Goitre which is associated with hypothyroidism or hyperthyroidism may be present with symptoms of the underlying disorder. For hyperthyroidism, the most common symptoms are associated with adrenergic stimulation: tachycardia, palpitations, nervousness, tremor, increased blood pressure and heat intolerance. Clinical manifestations are often related to hypermetabolism, including increased metabolism, excessive thyroid hormone, an increase in oxygen consumption, metabolic changes in protein metabolism, immunologic stimulation of diffuse goitre, and ocular changes (exophthalmos).[2] Hypothyroid individuals may have weight gain despite poor appetite, cold intolerance, constipation and lethargy. However, these symptoms are often nonspecific and hard to diagnose.

Morphology

Regarding morphology, goitres may be classified either as the growth pattern or as the size of the growth:

Growth pattern
Size

Causes

Worldwide, the most common cause for goitre is iodine deficiency, usually seen in countries that do not use iodized salt. Selenium deficiency is also considered a contributing factor. In countries that use iodized salt, Hashimoto's thyroiditis is the most common cause.[3] Goitre can also result from cyanide poisoning; this is particularly common in tropical countries where people eat the cyanide-rich cassava root as the staple food.[4]

Cause Pathophysiology Resultant thyroid activity Growth pattern Treatment Incidence and prevalence Prognosis
Iodine deficiency Hyperplasia of thyroid to compensate for decreased efficacy Can cause hypothyroidism Diffuse Iodine Constitutes over 90% cases of goitre worldwide[1] Increased size of thyroid may be permanent if untreated for around five years
Congenital hypothyroidism Inborn errors of thyroid hormone synthesis Hypothyroidism
Goitrogen ingestion
Adverse drug reactions
Hashimoto's thyroiditis Autoimmune disease in which the thyroid gland is gradually destroyed. Infiltration of lymphocytes. Hypothyroidism Diffuse and lobulated[5] Thyroid hormone replacement Prevalence: 1 to 1.5 in a 1000 Remission with treatment
Pituitary disease Hypersecretion of thyroid stimulating hormone, almost always by a pituitary adenoma[6] Diffuse Pituitary surgery Very rare[6]
Graves' disease—also called Basedow syndrome Autoantibodies (TSHR-Ab) that activate the TSH-receptor (TSHR) Hyperthyroidism Diffuse Antithyroid agents, radioiodine, surgery 1 to 2 cases per 1,000 population per year Remission with treatment, but still lower quality of life for 14 to 21 years after treatment, with lower mood and lower vitality, regardless of the choice of treatment[7]
Thyroiditis Acute or chronic inflammation Can be hyperthyroidism initially, but progress to hypothyroidism
Thyroid cancer Usually uninodular Overall relative 5-year survival rate of 85% for females and 74% for males[8]
Benign thyroid neoplasms Usually hyperthyroidism Usually uninodular Mostly harmless
Thyroid hormone insensitivity Secretional hyperthyroidism,
Symptomatic hypothyroidism 		Diffuse

Treatment

Goitre is treated according to the cause. If the thyroid gland is producing too much T3 and T4, radioactive iodine is given to the patient to shrink the gland. If goitre is caused by iodine deficiency, small doses of iodide in the form of Lugol's Iodine or KI solution are given. If the goitre is associated with an underactive thyroid, thyroid supplements are used as treatment. In extreme cases, a partial or complete thyroidectomy is required.[9]

Epidemiology

Disability-adjusted life year for iodine deficiency per 100,000 inhabitants in 2002.[10]
  no data
  fewer than 50
  50–100
  100–150
  150–200
  200–250
  250–300
  300–350
  350–400
  400–450
  450–500
  500–800
  more than 800

Goitre is more common among women, but this includes the many types of goitre caused by autoimmune problems, and not only those caused by simple lack of iodine.

History

Goitre and cretinism in Styria, copper engraving, 1815
Women in Miesbacher Tracht, including a goitre choker

Chinese physicians of the Tang Dynasty (618–907) were the first to successfully treat patients with goitre by using the iodine-rich thyroid gland of animals such as sheep and pigs—in raw, pill, or powdered form.[11] This was outlined in Zhen Quan's (d. 643 AD) book, as well as several others.[12] One Chinese book, The Pharmacopoeia of the Heavenly Husbandman, asserted that iodine-rich sargassum was used to treat goitre patients by the 1st century BC, but this book was written much later.[13]

In the 12th century, Zayn al-Din al-Jurjani, a Persian physician, provided the first description of Graves' disease after noting the association of goitre and exophthalmos in his Thesaurus of the Shah of Khwarazm, the major medical dictionary of its time.[14][15] Al-Jurjani also established an association between goitre and palpitation.[16] The disease was later named after Irish doctor Robert James Graves, who described a case of goitre with exophthalmos in 1835. The German Karl Adolph von Basedow also independently reported the same constellation of symptoms in 1840, while earlier reports of the disease were also published by the Italians Giuseppe Flajani and Antonio Giuseppe Testa, in 1802 and 1810 respectively,[17] and by the English physician Caleb Hillier Parry (a friend of Edward Jenner) in the late 18th century.[18]

Paracelsus (1493–1541) was the first person to propose a relationship between goitre and minerals (particularly lead) in drinking water.[19] Iodine was later discovered by Bernard Courtois in 1811 from seaweed ash.

Goitre was previously common in many areas that were deficient in iodine in the soil. For example, in the English Midlands, the condition was known as Derbyshire Neck. In the United States, goitre was found in the Great Lakes, Midwest, and Intermountain regions. The condition now is practically absent in affluent nations, where table salt is supplemented with iodine. However, it is still prevalent in India, China,[20] Central Asia, and Central Africa.

Goitre had been prevalent in the alpine countries for a long time. Switzerland reduced the condition by introducing iodised salt in 1922. The Bavarian tracht in the Miesbach and Salzburg regions, which appeared in the 19th century, includes a choker, dubbed Kropfband (struma band) which was used to hide either the goitre or the remnants of goitre surgery.[21]

Society and culture

In the 1920s wearing bottles of iodine around the neck was believed to prevent goitre.[22]

Notable cases

Heraldry

The coat of arms and crest of Die Kröpfner, of Tyrol showed a man "afflicted with a large goitre", an apparent pun on the German for the word ("Kropf").[27]

See also

References

  1. 1 2 R. Hörmann: Schilddrüsenkrankheiten. ABW-Wissenschaftsverlag, 4. Auflage 2005, Seite 15–37. ISBN 3-936072-27-2
  2. ↑ Porth, C. M., Gaspard, K. J., & Noble, K. A. (2011). Essentials of pathophysiology: Concepts of altered health states (3rd ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.
  3. ↑ Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson. Robbins Basic Pathology (8th ed.). Philadelphia: Saunders. ISBN 1-4160-2973-7.
  4. ↑ http://www.atsdr.cdc.gov/toxprofiles/tp8-c2.pdf
  5. ↑ Babademez MA, Tuncay KS, Zaim M, Acar B, Karaşen RM (2010). "Hashimoto Thyroiditis and Thyroid Gland Anomalies". Journal of Craniofacial Surgery 21 (6): 1807–1809. doi:10.1097/SCS.0b013e3181f43e32. PMID 21119426.
  6. 1 2 Thyrotropin (TSH)-secreting pituitary adenomas. By Roy E Weiss and Samuel Refetoff. Last literature review version 19.1: January 2011. This topic last updated: July 2, 2009
  7. ↑ Abraham-Nordling, Torring, Hamberger, Lundell, Tallstedt, Calissendorff, Wallin. Graves' Disease: A long-term quality-of-life follow-up of patients randomized to treatment with antithyroid drugs, radioiodine, or surgery, Thyroid 15, no. 11(2005), 1279–86
  8. ↑ Numbers from EUROCARE, from Page 10 in: F. Grünwald; Biersack, H. J.; Grںunwald, F. (2005). Thyroid cancer. Berlin: Springer. ISBN 3-540-22309-6.
  9. ↑ "Goiter – Simple". The New York Times.
  10. ↑ "Mortality and Burden of Disease Estimates for WHO Member States in 2002" (xls). World Health Organization. 2002.
  11. ↑ Temple, Robert. (1986). The Genius of China: 3,000 Years of Science, Discovery, and Invention. With a forward by Joseph Needham. New York: Simon and Schuster, Inc. ISBN 0-671-62028-2. Pages 133–134.
  12. ↑ Temple, Robert. (1986). The Genius of China: 3,000 Years of Science, Discovery, and Invention. With a forward by Joseph Needham. New York: Simon and Schuster, Inc. ISBN 0-671-62028-2. Page 134.
  13. ↑ Temple, Robert. (1986). The Genius of China: 3,000 Years of Science, Discovery, and Invention. With a forward by Joseph Needham. New York: Simon and Schuster, Inc. ISBN 0-671-62028-2. Pages 134–135
  14. ↑ Basedow's syndrome or disease at Who Named It? – the history and naming of the disease
  15. ↑ Ljunggren JG (August 1983). "[Who was the man behind the syndrome: Ismail al-Jurjani, Testa, Flagani, Parry, Graves or Basedow? Use the term hyperthyreosis instead]". Lakartidningen 80 (32–33): 2902. PMID 6355710.
  16. ↑ Nabipour, I. (2003). "Clinical Endocrinology in the Islamic Civilization in Iran". International Journal of Endocrinology and Metabolism 1: 43–45 [45].
  17. ↑ Giuseppe Flajani at Who Named It?
  18. ↑ Hull G (1998). "Caleb Hillier Parry 1755–1822: a notable provincial physician". Journal of the Royal Society of Medicine 91 (6): 335–8. PMC 1296785. PMID 9771526.
  19. ↑ "Paracelsus" Britannica
  20. ↑ "In Raising the World's I.Q., the Secret's in the Salt", article by Donald G. McNeil, Jr., December 16, 2006, New York Times
  21. ↑ Kropfband bei planet-wissen.de
  22. ↑ "ARCHIVED – Why take iodine?". Nrc-cnrc.gc.ca. 2011-09-30. Retrieved 2012-11-01.
  23. ↑ Lahita, Robert G.; Yalof, Ina. Women and Autoimmune Disease. HarperCollins. p. 158. ISBN 978-0-06-008149-2.
  24. ↑ Lawrence K. Altman, M.D. "Doctors Say Bush Is in Good Health". The New York Times. September 14, 1991.
  25. ↑ Lawrence K. Altman, M.D. "The Doctor's World; A White House Puzzle: Immunity Ailments", The New York Times. May 28, 1991
  26. ↑ "Hearst Magazines". elle.com.
  27. ↑ Fox-Davies, Arthur Charles (1904). The Art of Heraldry: An Encyclopædia of Armory. New York and London: Benjamin Blom, Inc. p. 413.

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