Toxic multinodular goitre & toxic adenoma
Autonomous thyroid hormone production from nodule(s)
Overview
Hyperthyroidism from autonomously functioning thyroid nodule(s) — a single toxic adenoma or a toxic multinodular goitre (Plummer's), typically in older patients. No eye signs (not autoimmune); the scan shows discrete 'hot' nodules. Definitive treatment is radioiodine or surgery.
Recognise
- Thyrotoxic features in an OLDER patient, often with AF or apathetic presentation (less florid)
- Nodular (not diffuse) goitre; NO Graves eye signs; TRAb negative
- Scan: one or more 'hot' (autonomous) nodules with suppressed surrounding uptake
Red flags
- Apathetic thyrotoxicosis in the elderly (AF, weight loss, low mood) — easily missed
- Compressive goitre (stridor, dysphagia) → imaging/surgery
Differentials & how to tell them apart
Investigations
TFTs (↓TSH ↑T4/T3), TRAb negative, radioiodine uptake scan (hot nodules), ultrasound for the goitre.
Management
Radioiodine or surgery (beta-blocker ± antithyroid drug as bridge)
- 1Confirm with uptake scan. Control symptoms with a beta-blocker ± antithyroid drug.Gate: Unlike Graves, nodular disease does NOT remit on antithyroid drugs — definitive radioiodine or surgery is required; a dominant 'cold' nodule needs cytology to exclude cancer
- 2Radioiodine (preferred for multinodular) or thyroidectomy for large/compressive goitres; levothyroxine afterwards as needed.
Key points
Older patient + nodular goitre + hot nodules + NO eye signs = toxic nodular disease (definitive treatment, not remission on drugs). Apathetic thyrotoxicosis with AF is the elderly trap.
Monitor & prognosis
TFTs; post-treatment thyroid status.
Good with definitive treatment.
Source: British Thyroid Association; CKS