What is Plummer Disease?
Plummer disease, also known as toxic multi-nodular goiter, is a condition where the thyroid gland develops multiple growths and produces too much thyroid hormone. The condition was first identified by an American doctor named Henry Plummer in 1913. It’s characterized by more than one “self-governing” or “autonomous” growth or nodule in the thyroid, sometimes accompanied by “nonautonomous” nodules.
These nodules can be solid, filled with fluid (cystic), or a mix of both. There might even be several small self-governing areas. This leads to a range of too much thyroid hormone, from a mild increase that doesn’t cause symptoms (subclinical hyperthyroidism) to a severe increase (thyrotoxicosis) that could manifest with significant symptoms.
On a special type of scan called nuclear medicine thyroid scintigraphy, the autonomous or “self-governing” nodules are hyperactive or “hot/warm”, meaning they’re producing too much thyroid hormone. The nonautonomous nodules, on the other hand, can be hypoactive (cold), meaning they’re less active, or normoactive, meaning they function normally.
What Causes Plummer Disease?
The thyroid gland can become enlarged due to persistent, mild stimulation, which can be natural, disease-related, or a mix of both. This continuous stimulation can cause the gland to overly grow and form lump-like structures. These structures or parts of the thyroid gland can then act independently without needing feedback from the pituitary hormone TSH. This whole process, over time, creates a condition known as toxic multinodular goiter, a type of enlarged thyroid. Some studies suggest that this disease develops from a widespread enlarged thyroid that, over time, develops into separate lumps.
Many factors can contribute to developing this disease, and they can be divided into primary and secondary factors. The primary factors include functional differences in the normal thyroid cells, most likely due to genetic issues, which allow the thyroid cells to gain new, inheritable traits while duplicating. A disease known as Plummer disease, another form of thyroid enlargement, becomes more common when there’s a family history of it. There’s also evidence pointing out that changes in certain genes on a particular chromosome result in Plummer disease. It has been observed that women tend to develop this condition more frequently than men.
Secondarily, factors such as elevated levels of TSH hormone, smoking, stress, certain medications, other agents stimulating the thyroid (like IGF-1), and internal factors (like gender), can contribute to the disease.
Research also suggests that low iodine levels might be involved. Lack of iodine can lead to thyroid gland enlargement due to increased TSH levels. But when iodine levels return to normal, or the thyroid doesn’t need it as much, the gland enters a resting phase. Switching between these two phases can cause a widespread enlargement of the thyroid, which could result in either a single nodule or multiple in the form of a non-toxic or toxic multinodular goiter. This is why the disease is more often seen later in life. The path from having a thyroid nodule to developing toxic multinodular goiter doesn’t have a fixed pattern.
Risk Factors and Frequency for Plummer Disease
Plummer disease, also known as toxic multinodular goiter, is the second most common cause of an overactive thyroid, or hyperthyroidism. The most common cause is Graves disease. Plummer disease is more frequently found in women. It is also commonly seen in people aged 50 and older, in both men and women. In contrast, Graves disease usually shows up in younger people. In Plummer disease, an overactive thyroid often develops after a long period of having a goiter (an enlarged thyroid), and it’s most common in people in their 60s and 70s, especially if they have a family history of toxic multinodular goiter.
- Plummer disease is the second most common cause of hyperthyroidism, after Graves disease.
- It is more common in women.
- It typically affects people aged 50 and over, in both men and women.
- Compared to Plummer disease, Graves disease usually affects younger people.
- In Plummer disease, an overactive thyroid typically develops after a long period of having an enlarged thyroid.
- It is most common in people in their 60s and 70s, especially if they have a family history of the disease.
Signs and Symptoms of Plummer Disease
When looking at a patient’s history for signs of possible thyroid issues, doctors consider various factors. These include the patient’s age and gender, where they’ve lived (as certain areas can have a higher rate of specific thyroid conditions), if they’ve been deficient in iodine, medication use, and if they’ve had any exposure to radiation. This could be from medical treatments or even from certain work environments. The doctor will also look for symptoms of an overactive thyroid (hyperthyroidism) and a thyroid gland that’s grown bigger (known as a goiter).
Hyperthyroidism symptoms can show up in different ways:
- Common Symptoms:
- Intolerance to heat
- Unexpected weight loss
- Shaking or trembling
- Fast heartbeat or irregular heartbeats
- Need to go to the bathroom more often
- Irregular periods
- Sweaty palms and excessive sweating
- Less Common Symptoms:
- Muscle wasting and difficulty with movements like getting up from a squatting position or going upstairs
- An irregular heart rhythm called atrial fibrillation
- Frequent bone fractures due to weakened bones (osteoporosis)
- A delay in the eyelid closing and an intense staring gaze
- Decreased sex drive
- Bedwetting in children
- Symptoms from Neck Mass:
- Shortness of breath
- Difficulty swallowing
- A hoarse voice
- Less commonly, compression of the trachea (windpipe)
When a doctor does a physical exam on a patient with thyroid issues, they often find multiple soft, smooth, and mobile nodules due to the enlarged thyroid gland. Other signs of hyperthyroidism can include flushing, sweating, thin hair and skin, eyelid delay and intense stare, tremors, irritability, hyperactivity, nervousness, mental disturbances, reflexes that are normal or heightened, and muscle weakness in the upper body.
It’s important to note that patients with a condition called Plummer disease often have fewer symptoms than those with Graves disease, which is another type of thyroid disorder.
Testing for Plummer Disease
If your doctor suspects you have Plummer disease, they will perform several tests. These involve laboratory and imaging studies to understand how your thyroid is functioning and if there are any unusual growths in your thyroid.
Your doctor may ask for a complete blood count and liver tests, especially if they are considering starting you on specific medication like methimazole or PTU, both of which are used to treat thyroid disease. They will also conduct a thyroid function test, where they will be looking at levels of TSH, T3 and T4 hormones in your blood. In most cases of Plummer disease, they will find that TSH is low, while T3 and T4 are high. Another set of tests is to check for antibodies that attack thyroid tissues, which are often present in Plummer disease.
In terms of imaging studies, your doctor might use an ultrasound to get an idea of how your thyroid looks. They will be looking at the number of nodules (or growths) and their sizes. A special kind of ultrasound called a Color Doppler can evaluate how much blood is flowing to the nodules.
A test called thyroid scintigraphy may also be done. This is a type of nuclear medicine test that uses the radioactive versions of iodine or technetium to visualize your thyroid. In Plummer disease, usually one or more nodules show increased radioactive uptake while the rest of the thyroid shows decreased uptake. This test is necessary to distinguish Plummer disease from other causes of hyperthyroidism.
Another test, known as fine needle aspiration cytology (FNAC), is used to collect cells from any suspicious nodules for lab analysis. This helps to ensure that there’s no thyroid cancer present.
In cases where detailed images of the thyroid gland are needed, your doctor might use CT and MRI scans. However, these are usually not the first choice for Plummer disease. Such scans give details about the size and location of your thyroid, which can be useful if your thyroid is enlarging behind your breastbone or if it’s growing back after treatment.
Your doctor might also use a laryngoscopy to check your windpipe and voice box. This test helps ensure that your windpipe isn’t getting squeezed by an enlarged thyroid. If you’re planning on having surgery, doctors use this test to document vocal cord movement before the procedure.
Treatment Options for Plummer Disease
If you are in the early stages of hyperthyroidism (overactive thyroid), your doctor might choose to monitor your condition without intervening right away. It’s recommended that you avoid excessive intake of iodine, which is found in certain supplements, medicines, and contrast dyes used for imaging tests. Those who are at risk of developing an irregular heart rhythm (atrial fibrillation) or have weakened bones (osteoporosis or osteopenia) should be treated, even if they have very minor hyperthyroidism due to an enlarged, overactive thyroid (toxic multinodular goiter).
Surgery is often the main treatment for toxic multinodular goiter. This can provide a fast solution with low risks. The surgical approach aims to keep a small, functioning part of the thyroid and avoid leaving behind any abnormal nodules. While this method has generally positive outcomes, it may increase the likelihood of the disease recurring later on. On the other hand, entirely removing the thyroid can also reduce this risk but may involve more complications. One expected outcome of surgery is hypothyroidism (underactive thyroid).
Possible complications of surgery include:
* Damage to certain nerves, causing vocal cord paralysis
* Low calcium levels due to damage to the parathyroid glands (hypoparathyroidism)
* Serious bleeding or infection after surgery
* Need for tracheostomy (a hole created in the windpipe)
Radioactive iodine ablation (RIA) can be used to treat Plummer disease, an overactive thyroid condition. Except for pregnant women, there are no absolute reasons why a patient couldn’t receive this treatment. This therapy is safe and effective but might not completely resolve the disease, and it might take some time to see results. There’s also a small increase in the risk of developing other types of cancer after radioactive iodine treatment.
Possible side effects of RIA include:
* Underactive thyroid
* Mild overactive thyroid symptoms
* Worsening of heart failure or irregular heartbeat symptoms
* Compression of the windpipe
* Very rarely, a severe form of overactive thyroid disease called thyroid storm
Anti-thyroid drugs, such as propylthiouracil and methimazole, may be used while waiting for RIA or surgery. Propylthiouracil is preferred for pregnant women in their first trimester. Over time, prolonged methimazole treatment has been shown to safely convert an overactive thyroid nodule to an underactive one.
In some cases, a minimally invasive procedure called ethanol ablation may be used to treat overactive thyroid nodules. This can be performed in an outpatient setting and is especially suitable for patients who are not fit enough for surgery. However, this treatment isn’t routinely done as it needs to be repeated weekly for several sessions. Though the initial results are promising, the long-term outcomes are less satisfactory.
Other medications may be used to manage symptoms associated with an overactive thyroid, like high blood pressure and a fast heartbeat. Beta-blockers are often used for this purpose.
What else can Plummer Disease be?
When trying to diagnose thyroid related issues, doctors have to consider and rule out multiple different conditions. These conditions could include:
- Diffuse toxic goiter (Also known as Graves disease)
- Subacute thyroiditis
- Hashimoto’s thyroiditis at the Hashitoxicosis stage
- Nontoxic goiter
- Thyroid nodule
- Nontoxic multinodular goiter (a goiter with multiple nodules that doesn’t cause an over or underactive thyroid)
- Papillary thyroid carcinoma (a common type of thyroid cancer)
- Riedel thyroiditis (a rare inflammatory disease of the thyroid)
- Struma ovarii (a rare condition where ovarian tissue contains thyroid tissue)
What to expect with Plummer Disease
There are certain types of toxic multinodular goiters—overactive thyroid nodules—that may not require treatment if they aren’t causing any symptoms, or their overactivity is not severe (with normal T4 and T3 hormone levels, and low TSH). Just to clarify: T4 and T3 are thyroid hormones; Tob high of these hormones indicate overactive thyroid and TSH is a hormone that controls thyroid function, too low means overactive thyroid.
However, if a multinodular goiter is causing noticeable symptoms, it may need to be removed surgically or treated with a procedure called radioactive ablation—using radiation to destroy the problematic thyroid tissue. Once the disease is treated, there’s a very low chance of it returning after surgery.
In general, Plummer’s disease, which is another term for toxic multinodular goiters, has a good outlook. It usually improves with treatment and the chances of it returning are low.
Possible Complications When Diagnosed with Plummer Disease
Plummer disease can cause a range of health issues. One of these could be the development of hyperthyroidism, along with the signs and symptoms this condition carries. This may cause conditions such as weakening of the bones, fast heart rate, erratic heart rhythms, heart failure, or even severe problems like bone fractures. Increased thyroid hormone levels can make heart conditions worse by making the body need more oxygen. It can also worsen lung conditions like asthma and COPD. Symptoms of other heart conditions like atherosclerotic cardiovascular disease and congestive heart failure can also get worse.
Another difficulty that Plummer disease can cause is a decrease in overall bone density. This could lead to accelerated bone loss as well as an increase in the level of calcium in the urine and the blood. There is also an increased chance of experiencing fractures due to weakened bones.
From time to time, the thyroid gland in people with Plummer’s disease might develop cancerous cells. This occurrence, alongside hyperthyroidism, has been observed in a small number of surgeries carried out for both conditions. Sometimes hemorrhage in the thyroid area can cause pain, especially if cystic nodules are present in a toxic multinodular goiter — a condition sometimes seen in Plummer disease.
Additional complications like a thyroid storm may take place due to factors such as infections or stress. This could lead to a worsening of symptoms, high fever, abdominal pain, and a decreased mental alertness, though it is less common in people with Plummer’s disease than in those with Graves’ disease.
Lastly, an increase in the size of the thyroid gland due to Plummer disease can put pressure on the windpipe and the food pipe, leading to conditions such as shortness of breath, a change in voice tone (due to pressure on a nerve in the throat), difficulty swallowing, a softening of the windpipe, and in severe cases, choking.
Complications due to Plummer disease:
- Progression of hyperthyroidism and its signs
- Increased chances of weakened bones, rapid heart rate, and heart failure
- Worsening of asthma and COPD symptoms
- A decrease in overall bone density
- Elevated calcium levels in urine and blood
- Increased risk of fractures
- Possibility of cancerous cells in the thyroid
- Pain in the thyroid area due to hemorrhage
- Possibility of a thyroid storm
- Pressure on the windpipe and food pipe
Preventing Plummer Disease
Doctors should explain to patients about the signs of their original health condition. Furthermore, they should mention if there are any likely signs of the condition worsening or coming back after starting a treatment plan. It’s highly important that patients understand the need to follow the medication guidelines and attend all follow-up appointments after a procedure. This is key to successfully managing their health condition.
