Goitre

Goitre
Classification and external resources
ICD-10	E01-E05
ICD-9	240.9
DiseasesDB	5332
MedlinePlus	001178
MeSH	D006042

A goitre or goiter (Latin gutteria, struma), is a swelling in the thyroid gland,^[1] which can lead to a swelling of the neck or larynx (voice box). Goitre rarely occurs when the thyroid gland is functioning properly.

Worldwide, over 90% cases of goitre are caused by iodine deficiency.^[2]

Signs and symptoms

Goitre associated with hypothyroidism or hyperthyroidism may present with symptoms of the underlying disorder although the symptoms are often unspecific and hard to diagnose.

Goitre not associated with hormonal abnormalities will not cause any symptoms aside from the presence of anterior neck mass. However, for particularly large masses, compression of the local structures may result in difficulty in breathing or swallowing. In those presenting with these symptoms, malignancy must be considered.

Toxic goitres will present with symptoms of thyrotoxicosis such as palpitations, hyperactivity, weight loss despite increased appetite, and heat intolerance.

Morphology

Struma nodosa (Class II)

Struma with autonomous adenoma

Struma Class III

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

Growth pattern

• Uninodular (struma uninodosa) - can be either inactive or a toxic nodule
• Multinodular (struma nodosa) - can likewise be inactive or toxic, the latter called toxic multinodular goitre
• Diffuse (struma diffuse), with the whole thyroid appearing to be enlarged.

Size

• Class I - palpation struma - in normal posture of the head, it cannot be seen; it is only found by palpation.
• Class II - the struma is palpative and can be easily seen.
• Class III - the struma is very large and is retrosternal; pressure results in compression marks.

Causes

Worldwide, the most common cause for goitre is iodine deficiency. Selenium deficiency is also considered a contributing factor. In countries that use iodized salt, Hashimoto's thyroiditis is the most common cause.^[3]

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[2]	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 thyroiditis	Autoimmune disease in which the thyroid gland is gradually destroyed	Hypothyroidism	Diffuse and lobulated[4]	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[5]		Diffuse	Pituitary surgery	Very rare[5]
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[6]
Thyroiditis	Acute or chronic inflammation	Can be hyperthyroidism initially, but progress to hypothyroidism
Thyroid cancer			Usually uninodular			Overall relative 5-year survival rate for of 85% for females and 74% for males[7]
Benign thyroid neoplasms		Usually hyperthyroidism	Usually uninodular			Mostly harmless
Thyroid hormone insensitivity		Secretional hyperthyroidism, Symptomatical hypothyroidism	Diffuse

• Sarcoidosis
• amyloidosis
• hydatiform mole
• cysts
• acromegaly

Epidemiology

Disability-adjusted life year for iodine deficiency per 100,000 inhabitants in 2002.^[8]

  no data

  less 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.

Some researchers ^[9] showed a correlation between Iodine-deficient goitre and gastric cancer, and reported in goitrous territories a decrease of the incidence of goitre and of stomach cancer after implementation of iodine-prophylaxis.^[10] The proposed mechanism of action is that iodide ion (I-) can function in thyroid gland and in gastric mucosa as an antioxidant ^[11] reducing species that can detoxify poisonous reactive oxygen species, such as hydrogen peroxide.

History

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.^[12] This was outlined in Zhen Quan's (d. 643 AD) book, as well as several others.^[13] 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.^[14]

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.^[15][16] Al-Jurjani also established an association between goitre and palpitation.^[17] 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,^[18] and by the English physician Caleb Hillier Parry (a friend of Edward Jenner) in the late 18th century.^[19]

Paracelsus (1493–1541) was the first person to propose a relationship between goitre and minerals (particularly lead) in drinking water.^[20] 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^[21] 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.^[22]

Society and culture

Famous goitre sufferers

• Edward Gibbon
• Kim Il-Sung
• Former President George H. W. Bush and his wife Barbara Bush both were diagnosed with Graves' disease and goitres, within two years of each other. In the president's case, the disease caused hyperthyroidism and cardiac dysrhythmia.^{[23][24][25][26]} Scientists said that the odds of both George and Barbara Bush having Graves’ disease might be 1 in 100,000 or as low as 1 in 3,000,000^[27]
• Andrea True (according to an interview on VH1)^[28]
• Umm Kulthum, a famous Egyptian singer, refused to undergo surgical treatment for fear of accidental injury of laryngeal nerves.

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.^[29]

See also

• Struma ovarii (a kind of teratoma)
• David Marine conducted substantial research on the treatment of goitre with iodine.
• Endemic goitre
• Graves' Disease (also known as Exophthalmic goitre or Basedow's disease)

References

1. ^ "goiter" at Dorland's Medical Dictionary
2. ^ ^{a b} R. Hörmann: Schilddrüsenkrankheiten. ABW-Wissenschaftsverlag, 4. Auflage 2005, Seite 15-37. ISBN 3-936072-27-2
3. ^ Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson. Robbins Basic Pathology. Philadelphia: Saunders. ISBN 1-4160-2973-7.  8th edition.
4. ^ Babademez, M. A.; Tuncay, K. S.; Zaim, M.; Acar, B.; Karaşen, R. M. (2010). "Hashimoto Thyroiditis and Thyroid Gland Anomalies". Journal of Craniofacial Surgery 21 (6): 1807–1809. doi:10.1097/SCS.0b013e3181f43e32. PMID 21119426.  edit
5. ^ ^{a b} 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
6. ^ 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
7. ^ Numbers from EUROCARE, from Page 10 in: F. Grünwald; Biersack, H. J.; Grںunwald, F. (2005). Thyroid cancer. Berlin: Springer. ISBN 3-540-22309-6. 
8. ^ "Mortality and Burden of Disease Estimates for WHO Member States in 2002" (xls). World Health Organization. 2002. http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls. 
9. ^ Abnet CC; Fan JH; Kamangar F et al. (September 2006). "Self-reported goitre is associated with a significantly increased risk of gastric noncardia adenocarcinoma in a large population-based Chinese cohort". Int. J. Cancer 119 (6): 1508–10. doi:10.1002/ijc.21993. PMID 16642482. 
   Venturi S, Venturi A, Cimini D, Arduini C, Venturi M, Guidi A (January 1993). "A new hypothesis: iodine and gastric cancer". Eur. J. Cancer Prev. 2 (1): 17–23. doi:10.1097/00008469-199301000-00004. PMID 8428171. 
   Venturi S, Donati FM, Venturi A, Venturi M, Grossi L, Guidi A (January 2000). "Role of iodine in evolution and carcinogenesis of thyroid, breast and stomach". Adv Clin Path 4 (1): 11–7. PMID 10936894. 
   
10. ^ Goł Kowski f, Szybiń Ski z, Rachtan J et al. (August 2007). "Iodine prophylaxis--the protective factor against stomach cancer in iodine deficient areas". Eur J Nutr 46 (5): 251–6. doi:10.1007/s00394-007-0657-8. PMID 17497074. 
11. ^ Venturi S, Venturi M (April 1999). "Iodide, thyroid and stomach carcinogenesis: evolutionary story of a primitive antioxidant?". Eur. J. Endocrinol. 140 (4): 371–2. doi:10.1530/eje.0.1400371. PMID 10097259. http://eje-online.org/cgi/pmidlookup?view=long&pmid=10097259. 
    
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 0671620282. Pages 133–134.
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 0671620282. Page 134.
14. ^ 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 0671620282. Pages 134–135
15. ^ Basedow's syndrome or disease at Who Named It? - the history and naming of the disease
16. ^ 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. 
17. ^ Nabipour, I. (2003). "Clinical Endocrinology in the Islamic Civilization in Iran". International Journal of Endocrinology and Metabolism 1: 43–45 [45] 
18. ^ Giuseppe Flajani at Who Named It?
19. ^ 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. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1296785. 
20. ^ "Paracelsus" Britannica
21. ^ "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
22. ^ Kropfband bei planet-wissen.de
23. ^ The Health and Medical History of President George Bush DoctorZebra.com. 8 August 2004. Retrieved 8 October 2006.
24. ^ "George H.W. Bush." NNDB.
25. ^ Robert G. Lahita and Ina Yalof. Women and Autoimmune Disease: The Mysterious Ways Your Body Betrays Itself. Page 158.
26. ^ Lawrence K. Altman, M.D. “Doctors Say Bush Is in Good Health.” The New York Times. September 14, 1991.
27. ^ Lawrence K. Altman, M.D. “The Doctor’s World; A White House Puzzle: Immunity Ailments.”, The New York Times. May 28, 1991]
28. ^ “Andrea True.” Elle.
29. ^ Fox-Davies, Arthur Charles (1904) (in English). The Art of Heraldry: An Encyclopædia of Armory. New York and London: Benjamin Blom, Inc.. p. 413. 

External links

• National Health Services, UK
• Network for Sustained Elimination of Iodine Deficiency
• Network for Sustained Elimination of Iodine Deficiency - alternate site at Emory University's School of Public Health
• A case and photograph of a huge goitre from Photobucket.com and Doctorkhodadoust.net