Kara Kaple-Walter
Differential Diagnosis I:
Nodular Thyroid Disease
Nodular thyroid disease is considered a differential diagnosis for Ms. L.M. based on the description of general appearance, physical exam, and past medical history. The thyroid gland normally enlarges in response to an increased secretion of TSH (thyroid secreting hormone), which increases the number of follicular cells forming hyperfunctioning nodules (McCance & Huether, 2014). Toxic multinodular goiter occurs as a result of these hyperfunctioning nodules, which in turn leads to hyperthyroidism (McCance & Huether, 2014). The classic clinical manifestations of hyperthyroidism develop slowly in nodular thyroid disease and are evidenced by palpable nodules or goiter (McCance & Huether, 2014).
Ms. L.M. presented with an enlarged thyroid upon physical examination and had other systemic symptoms such as muscle weakness with fine tremors, anxiety, and unexplained weight loss. These symptoms provide the rationale for suspecting Nodular Thyroid Disease as a differential diagnosis. Though there are similarities between the patient’s presentation and Nodular Thyroid Disease, Graves Disease is a more appropriate diagnosis in this instance. There are two major distinguishing clinical manifestations of Graves Disease and does not occur in Nodular Thyroid Disease. These signs and symptoms include exophthalmos and pretibial myxedema. Ms L.M. complained of warm, moist and flushed extremities and exophthalmos, in which these clinical finding are evidenced in Graves Disease. Nodular Thyroid Disease, on the other hand, is commonly caused by an iodine deficiency, and radioactive iodine is utilized in the differential diagnosis and evaluation of hyperthyroidism. An isotope scan is used and aids in the differentiation of the possible causes of thyroid dysfunction. Low uptake of iodine may indicate thyroiditis where as an elevated uptake could mean nodular thyroid disease or toxic multinodular goiter (McCance & Huether, 2014). Treatment may consist of radioactive iodine, antithyroid drugs, or possibly surgery (McCance & Huether, 2014).
(Goiter: CC, 2019)
Differential Diagnosis II:
Thyroid Carcinoma
(Goiter, 2019)
Thyroid carcinoma is the most common endocrine malignancy. Papillary and follicular carcinoma are the most frequent types of thyroid carcinoma, and typically lead to hyperthyroidism (McCance & Huether, 2014). Ms. L.M. presents with an unintentional weight loss and an enlarged thyroid gland, which are clinical findings consistent with the diagnosis of thyroid carcinoma (Thyroid Cancer, 2019). Another factor to consider is that certain genetic syndromes, such as familiar medullary cancer, can increase one’s risk of developing thyroid carcinoma (Thyroid Cancer, 2019). On this patient’s maternal side, thyroid conditions are prevalent. Ms. L.M. was unable to remember the name of the condition, but her mother is currently being prescribed thyroid medication. Additionally the patients grandmother had a thyroidectomy at age 45, but she was unable to recall the precipitating illness. These exam findings and the genetic components involved place this patient at risk for thyroid carcinoma and it is a justifiable differential diagnosis.
However, Ms. L.M. complained of protruding eyeballs in conjunction with a bulging neck mass. These symptoms describe exophthalmos and goiter, clinical distinctions that are specific to Graves Disease. This eliminates thyroid carcinoma as the presumed diagnosis. Diagnosis of thyroid carcinoma involves ultrasonography of the presumed malignancy, and staging can be obtained using aspiration of the thyroid nodule (McCance & Huether, 2014) Treatment for well differentiated thyroid carcinoma includes surgery, postoperative radioactive iodine therapy, and suppression of TSH with levothyroxine (McCance & Huether, 2014).
(Thyroid Cancer, 2019)
Differential Diagnosis III:
Thyrotoxic Crisis
Thyrotoxic crisis, also referred to as thyroid storm, is a rare but potentially fatal state that can develop spontaneously or in undiagnosed or untreated hyperthyroidism (McCance & Huether, 2014). Thyroid storm is exacerbated when the patient is exposed to external stresses such as emotional distress or physical trauma (McCance & Huether, 2014). Symptoms of thyrotoxic crisis are similar to hyperthyroidism. Clinical manifestations that Ms. L.M. exhibited include tachycardia, increased peristalsis leading to diarrhea, heart palpitations, and shakiness or tremors (Jr., 2019).
The aforementioned clinical manifestations reflect how Ms. L.M. presented, and provides the rationale for considering the differential diagnosis of thyrotoxic crisis. Despite the similarities between Thyrotoxic Crisis and Graves Disease, more research must be done to properly diagnose the condition. As previously mentioned, thyroid storm usually results from an excessive stress or trauma. Because Ms. L.M. was not subjected to excessive stress or trauma, thyroid storm is not considered the correct diagnosis for this patient. The treatment for Thyrotoxic Crisis is the use of drugs that block thyroid hormone synthesis, administration of steroids or iodine, and supportive care (McCance & Huether, 2014).
(Learning Radiology, 2015)
(Substernal Goiter, 2005)