By Tedler D. Depaynos, MD

The middle age lady initially consulted their Municipal Health Officer because she noticed that her heart beats were getting faster. They live upland where it is cold and surprisingly she appeared to be feeling warm sometimes and even perspiring when everyone was doubling their jackets and even wearing bonnets. They plant various vegetables along the mountainsides and the trails going to their farm appear to be getting longer because she observed that she was tiring now easily. Because of this she was convinced by her husband to seek consultation.
Their Municipal MD entertained the possibility of hyperthyroidism because of her “tachycardia” and irregular heartbeats or “arrhythmia” plus her “sweating” problem. Because he was not able to palpate any thyroid enlargement or “tumor” he referred her to a cardiologist who fortunately is their town mate and is based in their Provincial Hospital. It was fortunate that they just harvested their “cabbage” and they were scheduled to bring a truckload to the “vegetable bagsakan” which is near the hospital.
The experienced cardiologist gave an impression of “Toxic Goiter” or “Hyperthyroidism” which was confirmed by elevated thyroid hormones in the laboratory. She was prescribed one of the standard anti-thyroid drug which is suppose to decrease the secretion of thyroid hormones and propranolol which is usually prescribed to control the manifestations of excess thyroid hormones which is termed in general “toxic manifestations”. She was advised high calorie diet and also prescribed vitamins. She was also advised initial follow-up after 2 weeks which is a must when one is taking anti-thyroid drugs especially when one is just starting. Succeeding follow-ups depends on her response to the meds prescribed.
Most of the time, the excess thyroid hormone is secreted by an enlarged thyroid gland which may be diffused and smooth or multi-nodular. The former is called Grave’s disease in medical parlance and the latter Plummer’s disease. In some instances a solitary nodule is detected just like in this patient and it may be the culprit. The cause is complicated which is termed “immunologic.” Definitely it is not due to the vegetables that they produce.
Thyroid hormones control the body metabolism and when in excess the metabolism is likewise excessive. This is manifested by tachycardia, arrhythmia, increased perspiration, intolerance to heat and hyperactivity like tremors. The burning of calories is more than doubled so that there is continuing decrease in weight. In severe cases, gradual “bulging of the eyeballs” would be noticed and is termed “exopthalmia” which is more common in the so called Grave’s disease. Complications may also occur which may be due to the toxic manifestations like heart failure, malnutrition and visual defects.
While waiting for the payment of their produce which sometimes occurs after 3 to 4 days, she met a former classmate who used to work in a medical institution. She suggested that she undergo a repeat thyroid ultrasound (UTZ) in another center because the one done at the provincial hospital was essentially normal. The repeat revealed a small “nodule” and when she returned to the clinic of the cardiologist he unfortunately went out of town for a medical convention. She was referred then to a general surgeon whom her friend is very familiar with.
The surgeon agreed with the diagnosis and treatment of the cardiologist because the laboratory results were obvious. He advised her however that the treatment would just control the thyroid secretions but would not remove the cause of the secretions which most probably was the thyroid “nodule”. In short she was advised eventual surgery once the toxic manifestations are controlled with normal laboratory tests.
The patient was undecided so when she met her former classmate again they went to see an Endocrinologist upon her insistence, for possible Radioactive Iodine Therapy or 131 Iodine. The Endocrinologist however advised them that 131 Iodine is usually for super large goiter like in Grave’s disease and for solitary nodule like hers, surgery is preferred. Of course, the advice of Endocrinologists is based on many other factors and individual cases are separately appraised.
The patient eventually underwent thyroidectomy and completely recovered with no more medicines. She is always proud displaying her small almost invisible scar whenever she was asked especially during native gatherings. She is also always naming her handsome surgeon.**