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Error in Thyroid Case Report Toxic Nodular Goiter

AACE 2017 Annual Meeting – Case Report in Error

At the AACE 2017 Annual Meeting, Sarah Fishman, MD, PhD, of Lenox Hill Hospital, in New York, NY, presented a case report of a patient who developed thyroid disease after taking 2000 mcg per day of iodine in the form of a nutritional supplement containing iodine.  Left image iodine tablets used in event of nuclear power plant accident emergency .

This case is in error because the patient had pre-existing toxic nodular goiter with autonomous nodule. In these rare cases, Iodine is contraindicated because iodine will cause thyrotoxicosis. The iodine did not cause the underlying thyroid disease of toxic nodular goiter. This case report is a gross error.

Iodine Prevents GoiterThe reality is that iodine intake of 2,000 mcg per day is common in many Asian diets, which are high in Iodine, and these populations are healthy with no adverse effects.  This error was made because the authors are so focused on vilifying iodine, they missed the correct diagnosis of toxic nodular goiter with autonomous nodule.   Iodine is so safe, in 1924, the government mandated a program of salt iodination for the entire population resulting in considerable health benefits for the population.  The government also mandates 65 mg of iodine for the population surrounding a nuclear power plant accident.

multinodular goiterLeft image: Toxic nodular Goiter on radionuclide thyroid scan. Note multiple nodules. Iodine is contra-indicated as this will cause thyroid storm and thyro-toxicosis.

In general, Iodine serves to suppress thyroid function, and does not cause hyperthyroidism in the general population.  In agreement is Dr. Dayan in his 1996 article on Chronic Autoimmune Thyroiditis in the New England Journal (3):

“However, iodine reduces thyroid secretion in both subjects with thyroid autoantibodies and those without thyroid autoantibodies, suggesting that it acts by inhibiting the biosynthesis and release of thyroid hormone rather than by augmenting thyroid autoimmunity. “(3)

Conclusion: This Case Report is deceptive and misleading and misses the patient’s correct diagnosis.  Iodine did not cause the patient’s underlying thyroid disease of toxic nodular goiter with autonomous nodule.  Yes, Iodine did cause the thyrotoxicosis episode which resolved upon withdrawing the iodine.  Iodine is contra-indicated in these rare cases, and generally safe for the remainder of the population.

Articles with Related Interest:

Iodine Induced Hyperthyroidism

Making Smarter children with Maternal Iodine Supplements

Graves Remission with Iodine

Jeffrey Dach MD
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Links and references

1) May 04, 2017 Case: Dietary Supplement Use Leads to Thyroid Disease 

2) Oncology Nurse Advisor   Cassandra Pardini, PharmD
May 04, 2017 Case: Dietary Supplement Use Leads to Thyroid Disease 

3) Autoimmune_Thyroiditis_Dayan_NEJM_1996 (Full pdf)
http://www.ncbi.nlm.nih.gov/pubmed/8649497
N Engl J Med. 1996 Jul 11;335(2):99-107.
Chronic autoimmune thyroiditis. Dayan CM, Daniels GH.
“However, iodine reduces thyroid secretion in both subjects with thyroid autoantibodies and those without thyroid autoantibodies, suggesting that it acts by inhibiting the biosynthesis and release of thyroid hormone rather than by augmenting thyroid autoimmunity. “

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