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I have a puzzling case. 37 M seen by PCP April last year, felt ?enlarged thyroid . TSH normal . No antibodies done . USG showed multiple nodules, on R there were 2 solid nodules about 17 mm and 10 mm respectively and on L , there was a 12 mm circumscribed nodule in inferior aspect and larger 2.0-2.5 cm nodule in the posterior aspect of midportion of the L lobe. Pt had no sxs and have not noticed any enlargement. In March this year, pt now noticed sudden enlargement on left side while shaving more prominent when he hyperextended his neck. No hoarseness, dysphonia, dysphagia. No Neck pain. Again , PCP did US, on R multiple nodules ranging in size from 5 mm to 2 cm , the last being hypovascular. There was this nodule , solid, hypovascular in posterior aspect measuring 3.9 x 2.8 x 2.8 cm. Thyroid scan cold nodule on left correlating with the palpable entity which was really prominent on scan., on the right multiple cool nodules TSH now= 6.5 slightly high ( N=0.34 - 5.6 uIU/ml) Thyroid peroxidase Ab = 48 slightly high (N = 0-2 IU/ml) Thyroglobulin Antibodies = > 90 ( N=0-2 IU/ml) -don't know why this was ordered. No radiation exposure. + FHx = maternal aunt= Hashimoto's ; mother = lupus; father= rheumatoiod arthritis. On PE, no eye signs; thyroid about 2-3 X normal size; approximately 2.5 cm left nodule , nontender, firm , not hard thyroid gland, -LN, normal reflexes. FNAB (reviewed with pathologist) on the L nodule- no lymphocytes suggestive of Hashimoto's; there was NO colloid; cellular smear with follicular cells with groups showing nuclear overlapping. R thyoid gland= follicular cells, NO colloid. 1. I am at a loss what he has, his biopsy does not show a lot of inflammation suggestive of Hash, given the size and sudden growth, and no colloid , would you recommend surgery, how extensive? total or partial? or thyroid med suppression? 2. What do you think about thyroglobulin antibodies? Thank you very much for your help and opinion.
Sincerely,
Cheryl Almirante, MD
Response
Given the positive antibodies and elevated TSH, one can be sure that he does have Hashimoto's and is mildly hypothyroid. In this setting often the US reveals "pseudo-nodules" that represent differences in texture in the thyroid caused by the thyroiditis. However his nodules sound like real new growths, maybe follicular adenomas and it may be that he has both Hashimoto's and a multinodular goiter. Considering the histology which is meant to imply some degree of danger, young age, male sex, 4 cm size, and growth, removal by a surgeon specializing in this field would be a good option.
Leslie J De Groot,MD