Last updated:
March 19, 2026
Toxic Nodular Goitre
Toxic nodular goitre can be caused by a single nodule (toxic adenoma) or multiple nodules (toxic multinodular goiter, AKA Plummer’s disease). Toxic thyroid nodules are progressive and require ablation or surgery to definitively treat.
A toxic nodular goitre is the second most common cause of hyperthyroidism.
Toxic Adenoma
A toxic thyroid adenoma is caused by an autonomous solitary nodule within the thyroid.
- Risk factors
- Pathophysiology
- Activating mutation in the TSH receptor gene → monoclonal proliferation of follicular cells
- Signs and symptoms
- Symptoms of hyperthyroidism
- A palpable, solitary, large nodule
- Symptoms appear once the nodule is > 3cm
- Tracheal deviation if the nodule is large
- The nodules(s) may or may not be palpable
- Differentials
- Investigations
- TSH level, T3, and T4: Best initial diagnostic test
- Low TSH
- Elevated T3 and T4
- Radioactive iodine uptake scan (RAIU)
- Increased uptake by the ‘hot’ nodule
- Thyroid ultrasound to characterise and confirm the adenoma, and rule out malignancy
- ESR to rule out thyroiditis
- TSH receptor and TPO autoantibodies to rule out Graves’ disease
- Treatment
- Propranolol to control symptoms of hyperthyroidism
- Radioactive iodine therapy or surgery (thyroid lobectomy) is the definitive treatment
Toxic Multinodular Goitre (Plummer’s disease)
Toxic multinodular goitre is caused by several autonomous nodules within the thyroid.
They have an increased incidence in post-menopausal women.
- Risk factors
- Iodine deficiency
- Head and neck irradiation
- Age > 40 years
- Pathophysiology
- Activating mutation in the TSH receptor gene → monoclonal proliferation of follicular cells
- Signs and symptoms
- Symptoms of hyperthyroidism
- Dysphagia
- Hoarsness
- Dyspnoea
- Cough
- Choking
- Nodular thyroid gland on palpation
- Tracheal deviation
- Differentials
- Investigations
- TSH level, T3, and T4: Best initial diagnostic test
- Low TSH
- Elevated T3 and T4
- Radioactive iodine uptake scan (RAIU)
- Multiple hot and cold areas
- Thyroid ultrasound to characterise and confirm the adenoma, and rule out malignancy
- ESR to rule out thyroiditis
- TSH receptor and TPO autoantibodies to rule out Graves’ disease
- CT-scan of the neck for pre-operative evaluation
- Treatment
- Propranolol to treat symptoms of hyperthyroidism
- Radioactive iodine ablation is less likely to be successful for Plummer’s disease than for a toxic adenoma due to the large amounts of thyroid tissue needed to be ablated.
- Radioactive iodine therapy and surgery (total thyroidectomy) are the definitive treatments
Biochemistry
| ACTH | P: <80 ng/L |
| ALT | P: 5–35 U/L |
| Albumin | P: 35–50 g/L |
| Aldosterone | P: 100–500 pmol/L |
| Alk. phosphatase | P: 30–130 U/L |
| α-Amylase | P: 0–180 IU/dL |
| α-Fetoprotein | S: <10 kU/L |
| Angiotensin II | P: 5–35 pmol/L |
| ADH | P: 0.9–4.6 pmol/L |
| AST | P: 5–35 U/L |
| Bicarbonate | P: 24–30 mmol/L |
| Bilirubin | P: 3–17 μmol/L |
| BNP | P: <50 ng/L |
| CRP | P: <10 mg/L |
| Calcitonin | P: <0.1 mcg/L |
| Calcium (ionized) | P: 1.0–1.25 mmol/L |
| Calcium (total) | P: 2.12–2.60 mmol/L |
| Chloride | P: 95–105 mmol/L |
| Cholesterol | P: <5.0 mmol/L |
| VLDL | P: 0.128–0.645 mmol/L |
| LDL | P: <2.0 mmol/L |
| HDL | P: 0.9–1.93 mmol/L |
| Cortisol AM | P: 450–700 nmol/L |
| Cortisol Midnight | P: 80–280 nmol/L |
| CK ♂ | P: 25–195 U/L |
| CK ♀ | P: 25–170 U/L |
| Creatinine | P: 70–100 μmol/L |
| Ferritin | P: 12–200 mcg/L |
| Folate | S: 2.1 mcg/L |
| FSH | P: 2–8 U/L ♂; >25 menopause |
| GGT ♂ | P: 11–51 U/L |
| GGT ♀ | P: 7–33 U/L |
| Glucose (fasting) | P: 3.5–5.5 mmol/L |
| Growth hormone | P: <20 mu/L |
| HbA1C (DCCT) | B: 4–6% |
| HbA1C (IFCC) | B: 20–42 mmol/mol |
| Iron ♂ | S: 14–31 μmol/L |
| Iron ♀ | S: 11–30 μmol/L |
| Lactate (venous) | P: 0.6–2.4 mmol/L |
| Lactate (arterial) | P: 0.6–1.8 mmol/L |
| LDH | P: 70–250 U/L |
| LH | P: 3–16 U/L |
| Magnesium | P: 0.75–1.05 mmol/L |
| Osmolality | P: 278–305 mosmol/kg |
| PTH | P: 0.8–8.5 pmol/L |
| Potassium | P: 3.5–5.3 mmol/L |
| Prolactin ♂ | P: <450 U/L |
| Prolactin ♀ | P: <600 U/L |
| PSA | P: 0–4 mcg/mL |
| Protein (total) | P: 60–80 g/L |
| Red cell folate | B: 0.36–1.44 μmol/L |
| Renin (erect) | P: 2.8–4.5 pmol/mL/h |
| Renin (recumbent) | P: 1.1–2.7 pmol/mL/h |
| Sodium | P: 135–145 mmol/L |
| TBG | P: 7–17 mg/L |
| TSH | P: 0.5–4.2 mU/L |
| T4 | P: 70–140 nmol/L |
| Free T4 | P: 9–22 pmol/L |
| TIBC | S: 54–75 μmol/L |
| Triglycerides | P: 0.50–2.3 mmol/L |
| T3 | P: 1.2–3.0 nmol/L |
| Troponin T | P: <0.1 mcg/L |
| Urate ♂ | P: 210–480 μmol/L |
| Urate ♀ | P: 150–390 μmol/L |
| Urea | P: 2.5–6.7 mmol/L |
| Vitamin B12 | S: 0.13–0.68 nmol/L |
| Vitamin D | S: 50 nmol/L |
Arterial Blood Gases
| pH | 7.35–7.45 |
| PaCO₂ | 4.7–6.0 kPa |
| PaO₂ | >10.6 kPa |
| Base excess | ±2 mmol/L |
Urine
| Cortisol (free) | <280 nmol/24h |
| Hydroxyindole acetic acid | 16–73 μmol/24h |
| Hydroxymethylmandelic acid | 16–48 μmol/24h |
| Metanephrines | 0.03–0.69 μmol/mmol cr. |
| Osmolality | 350–1000 mosmol/kg |
| 17-Oxogenic steroids ♂ | 28–30 μmol/24h |
| 17-Oxogenic steroids ♀ | 21–66 μmol/24h |
| 17-Oxosteroids ♂ | 17–76 μmol/24h |
| 17-Oxosteroids ♀ | 14–59 μmol/24h |
| Phosphate (inorganic) | 15–50 mmol/24h |
| Potassium | 14–120 mmol/24h |
| Protein | <150 mg/24h |
| Protein/creatinine ratio | <3 mg/mmol |
| Sodium | 100–250 mmol/24h |
Haematology
| WCC | 4.0–11.0 ×10⁹/L |
| RBC ♂ | 4.5–6.5 ×10¹²/L |
| RBC ♀ | 3.9–5.6 ×10¹²/L |
| Hb ♂ | 130–180 g/L |
| Hb ♀ | 115–160 g/L |
| PCV ♂ | 0.4–0.54 L/L |
| PCV ♀ | 0.37–0.47 L/L |
| MCV | 76–96 fL |
| MCH | 27–32 pg |
| MCHC | 300–360 g/L |
| RDW | 11.6–14.6% |
| Neutrophils | 2.0–7.5 ×10⁹/L (40–75%) |
| Lymphocytes | 1.0–4.5 ×10⁹/L (20–45%) |
| Eosinophils | 0.04–0.44 ×10⁹/L (1–6%) |
| Basophils | 0–0.10 ×10⁹/L (0–1%) |
| Monocytes | 0.2–0.8 ×10⁹/L (2–10%) |
| Platelets | 150–400 ×10⁹/L |
| Reticulocytes | 0.8–2.0% / 25–100 ×10⁹/L |
| Prothrombin time | 10–14 s |
| APTT | 35–45 s |
Paediatric
| Pulse Rate (bpm) |
|---|
| Neonate | 140–160 |
| Infant <1yr | 120–140 |
| 1–5 years | 110–130 |
| 5–12 years | 80–120 |
| >12 years | 70–100 |
| Respiratory Rate (tachypnoea) |
|---|
| 0–2 months | ≥60/min |
| 2–12 months | ≥50/min |
| 1–5 years | ≥40/min |
| >5 years | ≥30/min |
| Blood Pressure (mmHg) |
|---|
| Term | 65/45 |
| 1 year | 75/50 |
| 4 years | 85/60 |
| 8 years | 95/65 |
| 10 years | 100/70 |
| Weight Formulas |
|---|
| 3–12 months | (a + 9)/2 kg |
| 1–6 years | 2a + 8 kg |
| >6 years | (7a − 5)/2 kg |
| Haemoglobin (g/dL) |
|---|
| Term newborn | 13–20 |
| 1 month | 11–18 |
| 2 months | 10–15 |
| 1–2 years | 10–13 |
| >2 years | 11–14 |
| MUAC (6 months–5 years) |
|---|
| Obese | >17.5 cm |
| Normal | 13.5–17.4 cm |
| At risk | 12.5–13.4 cm |
| Moderate malnutrition | 11.5–12.4 cm |
| Severe malnutrition | <11.5 cm |
| Developmental Milestones |
|---|
| Social smile | 1.5 months |
| Head control | 4 months |
| Sits unsupported | 7 months |
| Crawls | 10 months |
| Stands unsupported | 10–12 months |
| Walks | 12–13 months |
| Talks | 18 months |
| CSF WBC (/mm³) |
|---|
| Term newborn | 0–25 |
| >2 weeks | 0–5 |
