A three year old hyperactive female child presented with a midline neck swelling of one year duration. Clinical examination revealed a nodule in the isthmus of thyroid.Her Thyroid Stimulating Hormone (TSH) was suppressed and Free T3 and Free T4 levels were elevated. Radionuclide scintigraphy showed a hyperfunctioning nodule in the isthmus of thyroid. Patient was administered antithyroid medication and brought toeuthyroid state. Isthmectomy was done. Post-operative period was uneventful. Patient was discharged on third post-operative day and is on regular follow up.

Karunakaran, Poongkodi

Maharajan, Chandrasekaran

English

Otolaryngology online journal

 
 
 
 
 
Volume 3 Issue 1 2013                                                                    ISSN: 2250-0359 
 
A rare case of solitary toxic nodule in a 3yr old female child – a 
case report 
 
*Chandrasekaran Maharajan                                             *  Poongkodi Karunakaran 
 
 
*Madras Medical College 
 
 
ABSTRACT 
A three year old hyperactive female child presented with a midline neck swelling 
of one year duration. Clinical examination revealed a nodule in the isthmus of thyroid. 
Her Thyroid Stimulating Hormone (TSH) was suppressed and Free T3 and Free T4 levels 
were elevated. Radionuclide scintigraphy showed a hyperfunctioning nodule in the 
isthmus of thyroid. Patient was administered antithyroid medication and brought to 
euthyroid state. Isthmectomy was done. Post-operative period was uneventful. Patient 
was discharged on third post-operative day and is on regular follow up. 
 
KEY WORDS:   Toxic nodule, isthmectomy, scintigraphy 
 
CASE REPORT 
A three year old hyperactive female child presented with a neck swelling of one 
year duration. Patient had no other features suggestive of hyperthyroidism .There was no 
history of endocrine disorder or malignancy in the family. There was no exposure to 
radiation.  
Clinical examination revealed a well defined, non tender nodule in the isthmus of 
thyroid. She did not have any cervical lymphadenopathy. She had multiple café au-lait 
spots with irregular borders over the abdomen and right thigh. Ultrasound of the neck 
showed an isthmic nodule with increased vascularity. TSH was less than 0.01uIU/ml 
(reference range: 0.35-5.5 uIU/ml), Free T3 was 4.8 pg/ml (reference range: 1.7-4.2 
pg/ml) and FT4 was 3.5 ng/dl (reference range: 0.7-2 ng/dl).  Thus, the TSH was 
suppressed and FT3, FT4 levels were elevated. 99m Tc pertechnetate thyroid scintigraphy 
(Fig.1) showed 3% uptake and hyperfunctioning nodule in the isthmus of thyroid. Serum 
calcitonin, the tumour marker for medullary carcinoma was estimated. It was 3 pg/ml 
(Normal value:< 10pg/ml). FNAC was hemorrhagic with few scattered bare nuclei and 
inconclusive.  
 
Patient was given  antithyroid medication, carbimazole 2.5mgBD for 2 months. 
She became euthyroid and was taken up for surgery. Intraoperative finding was a well 
encapsulated isthmic nodule  measuring 3*3*1cm in size and the rest of the thyroid was 
normal(Fig.2). Hence, Isthmectomy was done. On macroscopic examination, it was an 
encapsulated, tan-brown nodule replacing entire isthmus. Cut section of the nodule 
showed central cystic change containing brown hemorrhagic fluid (Fig.3,4). 
Histopathological examination revealed a colloid cyst with papillary hyperplasia(Fig.5). 
 Post operative period was uneventful. Patient was discharged on third post 
operative day (Fig.6).  Patient is on regular follow up. 
 
DISCUSSION: 
  A true solitary nodule is quite rare in the first two decades of life1, 2. The 
prevalence of thyroid nodules in children is 0.22-1.35% as opposed to the adult 
population, in which the prevalence is closer to 4%. Suspected thyroid nodules merit 
close attention because the risk of malignancy is higher in children than adults. It is found 
that 20% of thyroid nodules in children harbour malignancy 3, 4. In addition, thyroid 
cancer is much more aggressive in children and is associated with early metastasis to 
regional lymph nodes and parenchymal organs, most commonly lung and bone. The risk 
of malignancy in hot nodules in children is estimated around 15% (compared with < 1% 
in adults). Thus, one major goal of the diagnostic evaluation of thyroid nodules is to 
differentiate thyroid cancers, especially aggressive lesions, from benign adenomas. 
   Most children with thyroid nodule come to the attention of a physician because of 
mass in the thyroid region. The majority of the children with autonomous thyroid nodules 
are clinically euthyroid, in contrast to adults5. Development of hyperthyroidism occurs 
predominantly in nodules greater than 3cm in diameter6, with a minimal volume of 16ml 
by ultrasound7. The early onset hyperthyroidism may be associated with McCune 
Albright syndrome, a syndrome characterized by polyostotic fibrous dysplasia, multiple 
café au-lait spots and hyperfunctioning endocrinopathies. It is more common in girls and 
the age of onset of hyperthyroidism is between 3 and 12 yrs. 
The differential diagnosis of thyroid nodules in children should also include other 
benign thyroid conditions such as: (i) congenital hypothyroidism due to 
dyshormonogenesis or ectopy, (ii) thyroid hemiagenesis, (iii) thyroglossal duct cyst, (iv) 
simple goiter, (v) cystic lesion, (vi) nodular hyperplasia, (vii) follicular adenoma, (viii) 
Graves’ disease and (ix) Hashimoto thyroiditis.  
Hence, to improve the preoperative diagnosis, a careful work-up comprising the 
patient’s history, clinical examination, laboratory tests, thyroid ultrasound, scintigraphy, 
fine-needle aspiration cytology (FNAC) and molecular studies, is necessary. 
Ultrasound is a safe and widely available technique, and is used as the first-line 
screening diagnostic test in all pediatric patients with thyroid nodules. Colour-Doppler 
sonography may be helpful in hyperfunctioning nodule indicating an intensive vascular 
flow within a highly vascularised lesion, and no visible flow through the remaining 
suppressed thyroid gland.  
 If a thyroid swelling is diagnosed as a truly solitary solid thyroid nodule, Fine 
Needle Aspiration cytology should be done to obtain definitive diagnosis. Radioisotope 
scintigraphy is helpful to classify its activity into hot, warm, or cold. Radioactive iodine 
uptake characteristics of nodules can direct treatment and assist in estimating risk of  
 
malignancy.  Radionuclide I123 scintigraphy enables to study both the trapping and 
organification by the nodules. On the other hand, Technetium pertechnetate image 
demonstrates only the trapping by the nodule. The diagnosis of a hyperfunctioning or hot 
nodule is established when the image reveals increased accumulation of the radioisotope 
in the nodule and decreased or absent uptake in the surrounding thyroid tissues.  
Surgical treatment is preferred for all children and adolescents with solitary toxic 
nodule after preoperative antithyroid mediation, because of the risks of thyroid 
carcinoma. If the nodule is present in a thyroid lobe, we proceed with 
hemithyroidectomy. If the nodule is in the isthmus, we prefer isthmectomy to 
hemithyroidectomy, because  hemithyroidectomy may cause compensatory hypertrophy 
of the opposite lobe due to the removal of larger volume of normally functioning thyroid 
tissue. In addition, isthmectomy has the advantage of avoiding injury to the recurrent 
layngeal nerve and parathyroids on both sides. It renders the patient euthyroid and gives 
better cosmesis. Antithyroid drug therapy is considered for short term preoperative 
management to bring the patient to euthyroid state. Administration of iodides is not 
indicated in the preoperative treatment of AFTNs. Radioiodine is not given in children 
because RAI may precipitate a malignant transformation at a later date.  
 
 
 
Clinical Photograph of the patient 
 
 
  
 
 
 
 
Image showing Tc 99 Scintigraphy performed on this patient 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
Per operative picture showing nodule arising from isthmus region 
 
 
 
Image showing cut section of the specimen  
 
REFERENCE: 
 
1. . Hung W (1999). Solitary thyroid nodules in 93 children and adolescents. Horm Res 
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2. Bauer AJ, Tuttle RM, Francis GL (2002). Differentiated thyroid carcinoma of children 
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3. Parcini F, DeGroot LJ, (2006). Thyroid neoplasia. In DeGroot LJ, Jameson JL(eds.), 
Endocrinology, fifth edition. Philadelphia: Elsevier-Saunders 2147-2180. 
4. Schlumberger MJ, (1998). Papillary and follicular thyroid carcinoma. N Engl J of Med 
338:297.  
5.Abe K, Konno M, Sato T, Matsuura N, (1980). Hyperfunctioning thyroid nodules in 
children. Am J Dis Child 134:961. 
6. BransamCJ, Jalbot CH, Henry J et al: Solitary toxic adenomaof thyroid gland, Br J 
Surg 66: 590, 1997. 
7. Emrich D,Erlenmaier U, Dohl M, et al: Determination of the autonomously 
functioning volume of thyroid, Eur J Nucl Med 20: 410, 1993. 
 
 
 
 
 

al: Solitary toxic adenomaof thyroid gland,

Differentiated thyroid carcinoma of children and adolescents. The Endocrinologist 12:135.

et al: Determination of the autonomously functioning volume of thyroid,

Hyperfunctioning thyroid nodules in children.

Papillary and follicular thyroid carcinoma.

Solitary thyroid nodules in 93 children and adolescents. Horm Res 52:15.

Thyroid neoplasia.

A rare case of solitary toxic nodule in a 3yr old female child – a case report

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A rare case of solitary toxic nodule in a 3yr old female child – a case report

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