Differentiating goiter from other diseases: Difference between revisions

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{{Goiter}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Goiter]]
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{ARK}}


==Overview==
==Overview==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
As goiter manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype.


OR
==Differentiating Goiter from other Diseases==
*As goiter manifests in a variety of clinical forms, [[differentiation]] must be established in accordance with the particular subtype. The following are the various differential diagnoses: <ref name="pmid3302898">{{cite journal| author=Mahoney CP| title=Differential diagnosis of goiter. | journal=Pediatr Clin North Am | year= 1987 | volume= 34 | issue= 4 | pages= 891-905 | pmid=3302898 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3302898  }} </ref>
**[[Anaplastic thyroid cancer|Anaplastic Thyroid Carcinoma]]
**[[Follicular thyroid cancer|Follicular Thyroid Carcinoma]]
**[[Medullary thyroid cancer|Medullary Thyroid Carcinoma]]
**[[Papillary thyroid cancer|Papillary Thyroid Carcinoma]]
**[[Sarcoma]]
**[[Lipomas]]
**[[Fibroma]]
**[[Thyroid]] [[lymphoma]]
**[[Hashimoto Thyroiditis|Hashimoto thyroiditis]]
**[[Riedel's thyroiditis|Riedel thyroiditis]]
**[[Subacute thyroiditis]]
**Infectious thyroiditis
**[[Parathyroid adenoma]]
**[[Parathyroid]] cyst
**[[Thyroglossal duct cyst]]
**[[Branchial cleft cyst]]
**Pseudo-goiter
**Thyroid abscess
**[[Thyroid nodule]]
**Granulomatous disease of the [[thyroid]]
**[[Lymphadenopathy]]
**Carotid artery aneurysm
**Lymphatic malformation ([[cystic hygroma]])
**[[Tumors]] of other structures in the [[neck]]


[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
=== Differentials of thyroid gland enlargement ===
 
The table below outlines the differential diagnoses of neck swelling due to [[thyroid gland]] enlargement:<ref>Thyroid adenoma. Wikipedia. https://en.wikipedia.org/wiki/Thyroid_adenoma Accessed on October 11, 2015</ref>
==Differentiating X from other Diseases==
{| style="border: 0px; font-size: 90%; margin: 3px; width: 600px" align="center"
*[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
| valign="top" |
*[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
|+
 
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Disease}}
*As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Findings}}
 
|-
===Preferred Table===
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Multinodular goiter]]
{|
| style="padding: 5px 5px; background: #F5F5F5;" |[[Multinodular goiter]] is the multinodular enlargement of the [[thyroid]] gland. They are large [[nodules]] of more than 1 cm that produces symptoms of [[hyperthyroidism]].
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
|-
! rowspan="2" |Diseases
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |[[Grave's disease]]
! colspan="4" |Laboratory Findings
| style="padding: 5px 5px; background: #F5F5F5;" |[[Grave's disease]] is an [[autoimmune disease]] that affects the [[thyroid]]. It frequently results in [[hyperthyroidism]] and an enlarged [[thyroid]]. [[Pretibial myxedema]] and [[infiltrative ophthalmopathy|ophthalmopathy]] are some of the findings of [[grave's disease]].
! colspan="4" |Physical Examination
|-
! colspan="4" |History and Symptoms
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |[[Hashimoto's disease]]
! rowspan="2" |Other Findings
| style="padding: 5px 5px; background: #F5F5F5;" |[[Hashimoto's disease]] is an [[autoimmune disease]] in which the [[thyroid]] gland is attacked by a variety of cell-mediated and antibody-mediated immune processes, causing primary [[hypothyroidism]].
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
|-
!Lab Test 1
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |[[Medullary thyroid carcinoma]]
!Lab Test 2
| style="padding: 5px 5px; background: #F5F5F5;" |[[Medullary thyroid carcinoma]] is a form of thyroid carcinoma which originates from the [[parafollicular cell]]s (C cells), which produce the [[hormone]] [[calcitonin]].
!Lab Test 3
|-
!Lab Test 4
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Thyroid lymphoma
!Physical Finding 1
| style="padding: 5px 5px; background: #F5F5F5;" | Thyroid lymphoma is a rare malignant [[tumor]] which manifests as rapidly enlarging neck mass causing respiratory difficulty.
!Physical Finding 2
!Physical Finding 3
!Physical Finding 4
!Finding 1
!Finding 2
!Finding 3
!Finding 4
|-
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 1
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |[[De Quervain's thyroiditis]]
|style="background: #F5F5F5; padding: 5px;" |
| style="padding: 5px 5px; background: #F5F5F5;" | [[De Quervain's thyroiditis]] is a subacute granulomatous [[thyroiditis]] preceded by an [[upper respiratory tract infection]].
|style="background: #F5F5F5; padding: 5px;" |
|style="background: #F5F5F5; padding: 5px;" |<nowiki>+</nowiki>
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|style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 2
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Acute suppurative thyroiditis
|style="background: #F5F5F5; padding: 5px;" |'''↑'''
| style="padding: 5px 5px; background: #F5F5F5;" |Acute suppurative thyroiditis  is an uncommon [[thyroid]] disorder usually caused by [[bacterial infection]].
|style="background: #F5F5F5; padding: 5px;" |
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|style="background: #F5F5F5; padding: 5px;" |-
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|style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 3
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |'''Toxic adenoma'''
|style="background: #F5F5F5; padding: 5px;" |
| style="padding: 5px 5px; background: #F5F5F5;" |Toxic adenoma and [[toxic multinodular goiter]] are results of focal/diffuse [[hyperplasia]] of [[thyroid]] follicular cells independent of [[TSH]] regulation. Findings of single or multiple [[nodules]] are seen on physical examination or [[thyroid]] scan.<ref name="pmid2040867">{{cite journal |vauthors=Laurberg P, Pedersen KM, Vestergaard H, Sigurdsson G |title=High incidence of multinodular toxic goitre in the elderly population in a low iodine intake area vs. high incidence of Graves' disease in the young in a high iodine intake area: comparative surveys of thyrotoxicosis epidemiology in East-Jutland Denmark and Iceland |journal=J. Intern. Med. |volume=229 |issue=5 |pages=415–20 |year=1991 |pmid=2040867 |doi= |url=}}</ref>
|style="background: #F5F5F5; padding: 5px;" |↓
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|style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 4
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Direct chemical toxicity with inflammation
|style="background: #F5F5F5; padding: 5px;" |
| style="padding: 5px 5px; background: #F5F5F5;" |[[Amiodarone]], [[sunitinib]], [[pazopanib]], [[axitinib]], and other [[tyrosine kinase inhibitors]] may also be associated with a destructive [[thyroiditis]].<ref name="pmid2258582">{{cite journal |vauthors=Lambert M, Unger J, De Nayer P, Brohet C, Gangji D |title=Amiodarone-induced thyrotoxicosis suggestive of thyroid damage |journal=J. Endocrinol. Invest. |volume=13 |issue=6 |pages=527–30 |year=1990 |pmid=2258582 |doi= |url=}}</ref><ref name="pmid24282820">{{cite journal |vauthors=Ahmadieh H, Salti I |title=Tyrosine kinase inhibitors induced thyroid dysfunction: a review of its incidence, pathophysiology, clinical relevance, and treatment |journal=Biomed Res Int |volume=2013 |issue= |pages=725410 |year=2013 |pmid=24282820 |pmc=3824811 |doi=10.1155/2013/725410 |url=}}</ref>
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|style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 5
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Palpation thyroiditis
|style="background: #F5F5F5; padding: 5px;" |
| style="padding: 5px 5px; background: #F5F5F5;" |Manipulation of the [[thyroid gland]] during [[thyroid]] [[biopsy]] or neck [[surgery]] and vigorous palpation during the physical examination may cause transient hyperthyroidism.
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===Use if the above table can not be made===
=== Differentials of thyroid gland enlargement and thyrotoxicosis ===
{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px" align=center
The following table summarizes the various differential diagnoses of [[thyroid gland]] enlargement plus thyrotoxicosis and their major features:
|valign=top|
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Cause of thyrotoxicosis}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Differential Diagnosis}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|TSH receptor antibodies}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Similar Features}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Thyroid US}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Differentiating Features}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Color flow Doppler}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Radioactive iodine uptake/Scan}}
! colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" | {{fontcolor|#FFFFFF|Other features}}
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Graves' disease}}
| style="padding: 5px 5px; background: #F5F5F5;" | +
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Ophthalmopathy, [[dermopathy]], acropachy
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic nodular goiter}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Multiple nodules
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodules at thyroid scan
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Toxic adenoma}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Single nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Hot nodule
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subacute thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;" | -
| style="padding: 5px 5px; background: #F5F5F5;" | Heterogeneous hypoechoic areas
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | Neck pain, fever, and<br> elevated inflammatory index
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|Differential 1
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Painless thyroiditis}}
| style="padding: 5px 5px; background: #F5F5F5;"|
| style="padding: 5px 5px; background: #F5F5F5;" | -
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" | Hypoechoic pattern
| style="padding: 5px 5px; background: #F5F5F5;"|
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | -
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|Differential 2
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Amiodarone induced thyroiditis-Type 1}}
| style="padding: 5px 5px; background: #F5F5F5;"|
| style="padding: 5px 5px; background: #F5F5F5;" | -
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" | Diffuse or nodular goiter
| style="padding: 5px 5px; background: #F5F5F5;"|
| style="padding: 5px 5px; background: #F5F5F5;" | ↓/Normal/↑
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" | ↓ but higher than in Type 2
| style="padding: 5px 5px; background: #F5F5F5;" | High urinary iodine
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|Differential 3
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Amiodarone induced thyroiditis-Type 2}}
| style="padding: 5px 5px; background: #F5F5F5;"|
| style="padding: 5px 5px; background: #F5F5F5;" | -
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" | Normal
| style="padding: 5px 5px; background: #F5F5F5;"|
| style="padding: 5px 5px; background: #F5F5F5;" | Absent
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" | ↓/absent
| style="padding: 5px 5px; background: #F5F5F5;" | High urinary iodine
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|Differential 4
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Central hyperthyroidism}}
| style="padding: 5px 5px; background: #F5F5F5;"|
| style="padding: 5px 5px; background: #F5F5F5;" | -
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" | Diffuse or nodular goiter
| style="padding: 5px 5px; background: #F5F5F5;"|
| style="padding: 5px 5px; background: #F5F5F5;" | Normal/↑
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" | Inappropriately normal or high TSH
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|Differential 5
| colspan="1" rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Factitious thyrotoxicosis}}
| style="padding: 5px 5px; background: #F5F5F5;"|
| style="padding: 5px 5px; background: #F5F5F5;" | -
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" | Variable
| style="padding: 5px 5px; background: #F5F5F5;"|
| style="padding: 5px 5px; background: #F5F5F5;" | Reduced/absent flow
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
| style="padding: 5px 5px; background: #F5F5F5;" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" | ↓ Serum thyroglobulin
|}
|}


Latest revision as of 19:08, 25 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Reddy Kothagadi M.B.B.S[2]

Overview

As goiter manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype.

Differentiating Goiter from other Diseases

Differentials of thyroid gland enlargement

The table below outlines the differential diagnoses of neck swelling due to thyroid gland enlargement:[2]

Disease Findings
Multinodular goiter Multinodular goiter is the multinodular enlargement of the thyroid gland. They are large nodules of more than 1 cm that produces symptoms of hyperthyroidism.
Grave's disease Grave's disease is an autoimmune disease that affects the thyroid. It frequently results in hyperthyroidism and an enlarged thyroid. Pretibial myxedema and ophthalmopathy are some of the findings of grave's disease.
Hashimoto's disease Hashimoto's disease is an autoimmune disease in which the thyroid gland is attacked by a variety of cell-mediated and antibody-mediated immune processes, causing primary hypothyroidism.
Medullary thyroid carcinoma Medullary thyroid carcinoma is a form of thyroid carcinoma which originates from the parafollicular cells (C cells), which produce the hormone calcitonin.
Thyroid lymphoma Thyroid lymphoma is a rare malignant tumor which manifests as rapidly enlarging neck mass causing respiratory difficulty.
De Quervain's thyroiditis De Quervain's thyroiditis is a subacute granulomatous thyroiditis preceded by an upper respiratory tract infection.
Acute suppurative thyroiditis Acute suppurative thyroiditis is an uncommon thyroid disorder usually caused by bacterial infection.
Toxic adenoma Toxic adenoma and toxic multinodular goiter are results of focal/diffuse hyperplasia of thyroid follicular cells independent of TSH regulation. Findings of single or multiple nodules are seen on physical examination or thyroid scan.[3]
Direct chemical toxicity with inflammation Amiodarone, sunitinib, pazopanib, axitinib, and other tyrosine kinase inhibitors may also be associated with a destructive thyroiditis.[4][5]
Palpation thyroiditis Manipulation of the thyroid gland during thyroid biopsy or neck surgery and vigorous palpation during the physical examination may cause transient hyperthyroidism.

Differentials of thyroid gland enlargement and thyrotoxicosis

The following table summarizes the various differential diagnoses of thyroid gland enlargement plus thyrotoxicosis and their major features:

Cause of thyrotoxicosis TSH receptor antibodies Thyroid US Color flow Doppler Radioactive iodine uptake/Scan Other features
Graves' disease + Hypoechoic pattern ↑ ↑ Ophthalmopathy, dermopathy, acropachy
Toxic nodular goiter - Multiple nodules - Hot nodules at thyroid scan -
Toxic adenoma - Single nodule - Hot nodule -
Subacute thyroiditis - Heterogeneous hypoechoic areas Reduced/absent flow ↓ Neck pain, fever, and
elevated inflammatory index
Painless thyroiditis - Hypoechoic pattern Reduced/absent flow ↓ -
Amiodarone induced thyroiditis-Type 1 - Diffuse or nodular goiter ↓/Normal/↑ ↓ but higher than in Type 2 High urinary iodine
Amiodarone induced thyroiditis-Type 2 - Normal Absent ↓/absent High urinary iodine
Central hyperthyroidism - Diffuse or nodular goiter Normal/↑ ↑ Inappropriately normal or high TSH
Factitious thyrotoxicosis - Variable Reduced/absent flow ↓ ↓ Serum thyroglobulin

References

  1. ↑ Mahoney CP (1987). "Differential diagnosis of goiter". Pediatr Clin North Am. 34 (4): 891–905. PMID 3302898.
  2. ↑ Thyroid adenoma. Wikipedia. https://en.wikipedia.org/wiki/Thyroid_adenoma Accessed on October 11, 2015
  3. ↑ Laurberg P, Pedersen KM, Vestergaard H, Sigurdsson G (1991). "High incidence of multinodular toxic goitre in the elderly population in a low iodine intake area vs. high incidence of Graves' disease in the young in a high iodine intake area: comparative surveys of thyrotoxicosis epidemiology in East-Jutland Denmark and Iceland". J. Intern. Med. 229 (5): 415–20. PMID 2040867.
  4. ↑ Lambert M, Unger J, De Nayer P, Brohet C, Gangji D (1990). "Amiodarone-induced thyrotoxicosis suggestive of thyroid damage". J. Endocrinol. Invest. 13 (6): 527–30. PMID 2258582.
  5. ↑ Ahmadieh H, Salti I (2013). "Tyrosine kinase inhibitors induced thyroid dysfunction: a review of its incidence, pathophysiology, clinical relevance, and treatment". Biomed Res Int. 2013: 725410. doi:10.1155/2013/725410. PMC 3824811. PMID 24282820.

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