A 55 y.o woman comes to the ED with shortness of breath

A 55 y.o. woman from Nepal comes to the ED with shortness of breath.

What do you notice in the picture?

Our patient had a giant goiter with normal thyroid function.  Up to 25-35% of patients with giant goiters have upper airway obstruction symptoms and 10% require emergency intubation.

The history of goiters is interesting.  Goiters were first described in Chinese writings around 2700 BC. They were initially treated with a diet of seaweed.  The term “goiter” is thought to have originated from the Latin term guttur, meaning “ larynx” of the bronchus because it was thought to be a hernia of the larynx.

In the 1500’s  realism became a feature in paintings and goiters began to appear in paintings by da Vinci and Boticelli . They were almost never seen in Venetian paintings presumably because seafood was plentiful.

Boticelli’s Virgin with a goiter

Iodine  was discovered in  the 19th century Baumann discovered a high level of iodine was present in the thyroid glands of sheep.  Sheep thyroid was subsequently used by a Swiss physician to successfully treat a goiter. This became the accepted way to treat goiters. In 1914 thyroxine crystals were first isolated .Goiters persisted, however, because Iodine is found sporadically around the world in drinking water leading to pockets of iodine deficiency.

Much of the US is iodine deficient especially the great lakes region. Salt was iodized in the 1920’s and goiters largely decreased in the US.  Iodized salt however has never been mandated and those using Kosher or sea salt  do not receive supplementation. Half of prenatal vitamins do not contain iodine. Iodine deficiency in pregnant women leads to cretinism in the offspring.

The recent increase in goiters has been postulated because of general decrease in salt with the knowledge of its effects on hypertension. Iodine depleted areas persist. Local salt, without iodine, was found in Nepal and India leading to a goiter belt in the Himalayas prior to supplemental of salt with iodine. In addition to iodine deficiency; cassava, excess iodine, iron deficiency and cruciferous vegetables that have metabolites which compete with iodine for uptake by the thyroid. These and other drugs can cause hypothyroidism.

Iodine, element 53, is crucial for fetal development since thyroid hormone is needed for neuronal migration and synapse formation. Hypothyroidism in development causes irreversible mental retardation; a condition called cretinism. 

FUN FACT 

Gandhi is known for leading a protest against Britain  in India because of a salt tax on British iodized salt.  Local people could make salt from sea water but it was banned in India leading to Gandhi’s revolt. Half of the people of India still do not have access to iodized salt.

Our patient underwent a total thyroidectomy with partial reimplantation of the parathyroids and successfully recovered.

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Paudyal N, Chitekwe S, Rijal S, et al. the evolution, progress, and future direction of Nepal’s universal salt iodization program. Maternal and Child Nutrition. Feb 2020 ihttps://doi.org/10.1111/mcn.12945

Ashrafian H, Goiters in the Renaissance era: multiple cases of thyroid autoimmunity and iodine deficiency. Best Practic & Research Clinical endocrinology& Metabolism Volu 36(2) March 2024.

Basoglu M, Ozturk G, Aydinli B, et al. Benign nodular goiter causing upper airway obstruction. Eurasian J Med. 2009 Aug;41(2): 75-79