This is part of our House MD Project series.

Click here to read the connection to the episode (spoiler alert!) On episode 3 of season 8 (named “Charity Case”), altruist millionaire Benjamin Byrd collapses in the street right after he donated a large sum of money to another foundation. The team argues wether his altruism is a symptom or not, and meanwhile he develops tachycardia (fast heartbeat) and his hands are shaking. When he offers to donate both his kidneys the presence of mental symptoms is obvious, and when understanding that his symptoms got worse after he received contrast media containing iodine, he is diagnosed with Plummer’s Disease. .

Danger level: Low

What is it?

In Plummer’s Disease (also known as Toxic Nodular Goiter), an area in the thyroid gland works with no control, and causes a state called hyperthyroidism – too much thyroid hormone in the blood.

Who gets it?

The disease is responsible for 15-30% of the hyperthyroidism cases. It usually develops in adults older than 50, and is more common in women. The disease is also more common in areas of the world where iodine deficiency is common.

What causes it?

As explained before about another disease which causes hyperthyroidism (Graves Disease), the thyroid gland normally produces thyroid hormone in response to a molecule called TSH that comes from the brain. In Plummer’s disease, an area in the thyroid gland (a nodule) starts producing thyroid hormone independently – without TSH. Such nodules are called toxic nodules – there is also such thing as non-toxic nodules, which don’t produce thyroid hormone or any other substance.

The disease is related to exposure to iodine (which is an important factor in the function of the thyroid gland).

How does it feel?

Plummer’s disease can cause symptoms that are related to hyperthyroidism and symptoms that are related to the presence of the nodules themselves.

• Hyperthyroidism can cause weight loss with increased appetite, frequent bowel movements, tremor, intolerance to heat, heart palpitations and a fast heart beat (tachycardia), hyperactivity and irritability and muscle weakness.
• If the nodule is large enough, you can see an enlargement of the gland called goiter, that looks like this:

This is a very large goiter (very rare today).

• Also, when the nodule is very large, it may compress other organs in the neck and cause problems with breathing and swallowing, and sometimes also hoarseness or voice changes.

How is it discovered?

First, the doctor will want to check if the level of thyroid hormone in the blood is high. This can be done by testing the levels of the hormone itself and also by checking the levels of TSH (which will be low).

Ultrasound of the thyroid gland can help recognize nodules in the thyroid (which look like balls in different sizes), and another test called thyroid scan can differentiate between toxic and non-toxic nodules. Sometimes the doctor will want to take a biopsy from the nodule to make sure that it’s not cancer.

How is it treated?

There are two ways to treat Plummer’s disease – the first one is to remove the toxic nodule in surgery (like on the House episode), and the second is to use radioactive iodine that is injected to the bloodstream, concentrates in the nodule and destroys it.

What happens after treatment?

Treatment usually cures the disease, but even when untreated the disease is usually not life threatening (though it’s not very pleasant to live with).

The bottom line – how do I avoid it?

Most of the time there is no specific way to prevent the disease. People with low levels of iodine in their blood are at risk for the disease, so it’s important to consume enough iodine in the diet. In the United States iodine is added to table salt and other foods so iodine deficiency in the diet is very rare.

Related posts:

1. Graves Disease – Why Some People Are Hyperactive For A Reason
2. Appendicitis – A Small Part of The Intestine That Can Cause Big Trouble
3. Hashimoto’s Thyroiditis – Do You Suffer From Weight Gain, Fatigue or Hair Loss? This Might Just Be The Cause

Danger level: Medium

What is it?

Hashimoto’s Thyroiditis (or in short Hashimoto) is a disease that affects the thyroid gland, causing it to function less than it should.

Who gets it?

As many as 3.5 out of 1000 women, and 0.8 out of 1000 men have Hashimoto’s in the United States (all over the world it’s around 0.3-1.5 per 1000 people).

As you can see, it’s about 10-15 times as common in women than in men. The most common age of getting Hashimoto is 30-50.

What causes it?

Hashimoto is an autoimmune disease – This means the body’s immune system, which was meant to attack infections, attacks the body for some reason. (We discussed other autoimmune diseases here previously, like Graves, Lupus, Celiac, Myasthenia Gravis, Vitiligo).

In Hashimoto, antibodies (the molecules of the immune system) attack our thyroid gland.

Our thyroid gland produces hormones called T3 and T4, which are responsible for a few things in our body:

1. Increasing our metabolic rate, or energy
2. Help with the growth of bones
3. They increase our sensitivity to adrenaline

These are just some of their roles.

Since in Hashimoto the thyroid is attacked, less hormones are produced.

The thyroid gland in the neck. The body attacks it in Hashimoto.

How does it feel?

The condition that is caused by a lack of thyroid hormones is called hypothyroidism (there’s a name for it since this disease isn’t the only one that causes it. We’ll discuss others that do the same thing in the future).

Here are the features of hypothyroidism -

1. Loss of energy
2. Difficulty losing weight
3. Cold extremities
4. Sensitivity to cold
5. Difficulty concentrating
6. Depressed mood
7. Hair loss
8. Dry skin
9. Constipation
10. Fluid retention
11. Muscle pain and cramps

These are just the main symptoms. There are even more. This video sums it all up nicely -

How is it discovered?

To discover the disease, blood tests are performed. In them, the doctor will look for levels of the thyroid hormones, T3 or T4, and for the levels of a substance called TSH, which rises in hypothyroidism (to understand why, you can read about Graves disease, where the “feedback mechanism” is explained). Another thing that can be tested is the levels of the antibodies that attack the thyroid.They can also be found in the blood.

The problem is that not every doctor will think about this disease on time, since the symptoms above might hint at other diseases, such as depression.

How is it treated?

The treatment is very simple – your doctor will give you a drug called L-thyroxine, which is simply a synthetic version of the thyroid’s T4 hormone.

What happens after treatment?

With the appropriate treatment, people with Hashimoto can lead a normal life.

It’s important to remember that treatment is necessary – Without treatment, a state called a myxedema coma can develop, which has a 60% chance of mortality.

The bottom line – How Do I avoid it?

There are cases when Hashimoto might be more common, and in these cases it’s recommended to test the TSH levels in the blood once a year. These cases include:

1. Elderly people: Hypothyroidism is more common in the elderly. The symptoms in the elderly might me more subtle, so they might not even suspect having it.
2. People with other autoimmune diseases, such as Addison disease, type 1 diabetes, vitiligo, pernicious anemia, lupus.
3. People who have the disease running in their family.
4. People with Down syndrome, or with Turner syndrome.

Detecting the disease early on will not prevent it, but might lead to an earlier treatment.

Related posts:

1. Fibromyalgia – Chronic Pain and Fatigue
2. Meniere’s Disease – From Head Spinning To Hearing Loss
3. Labyrinthitis – An Ear Infection Causing Loss of Balance

Danger Level: Medium 

What is it?

Graves disease is an immune disorder of the thyroid gland in which the gland works overtime.

Who gets it?

About 2% of women, and 0.2% of men. Usually it begins between ages 20-50.

What causes it?

As explained in another disease of this kind (the auto-immune kind) – Lupus, although our body’s immune system creates molecules called antibodies to fight infections, sometimes, for reasons unknown, these antibodies can also attack the body itself.

To understand how these antibodies work, we first need to understand how the thyroid gland works.

In order for the thyroid gland to do its job, the brain sends it a command to work. It does so by sending a molecule called TSH to the gland. When it receives this molecule, through a receptor inside the gland, it starts producing the thyroid hormones, that are responsible for regulating different things in our body.

In graves disease the antibodies mentioned before attack the TSH receptor and cause it to work all the time, as if the brain is constantly sending TSH. This causes the thyroid gland to over-function, a condition called hyperthyroidism.

How does it feel?

There are many manifestations to the disease. They can be divided in two:

1. Symptoms that are related to the thyroid gland’s over function – they can also be seen in other conditions that cause the thyroid to over function:

• Hyperactivity and irritability
• Heat intolerance and sweating
• Heart palpitations
• Fatigue and weakness
• Weight loss with increased appetite
• Diarrhea
• Increased urination
• Tremor of the body
• Warm, moist skin
• Muscle weakness
• Goiter – this is an enlargement of the gland, as seen in this picture:

A woman with a goiter. You won’t see goiters these large today.

2. Symptoms that are related to Graves disease:

One of the main features in Graves is an eye problem, called an exophthalmus. What it means is simply “bulging of the eyes”, as can be seen in this picture:

How is it discovered?

By a blood test: It will show that the thyroid hormones are way up, and that TSH itself is low – the brain doesn’t send it anymore because it sees there are enough hormones already.

How is it treated?

There are 3 ways:

1. Antithyroid Drugs: These are drugs that cause the thyroid to produce less of its hormones. They are called Propylthiouracil and Methimazole.

2. Radioactive iodine: One of the materials needed to create thyroid hormones is iodine. The thyroid glands takes it from the blood and uses it to create its hormones. When it takes iodine that’s radioactive, the gland is destroyed and so can’t produce all those extra hormones.

3. Surgery: In which the gland is taken out, also stopping the over-releasing of hormones.

What happens after treatment?

In about 18-24 months, the antithyroid drugs are fully effective and the hormones return to normal. With radioactive treatment, it takes about 2-3 months for a full effect. In some cases the disease can return after treatment.

The cause of Graves disease, like other autoimmune diseases, isn’t known. There is nothing you can do to prevent it from coming.

Related posts:

1. Hashimoto’s Thyroiditis – Do You Suffer From Weight Gain, Fatigue or Hair Loss? This Might Just Be The Cause
2. Plummer’s Disease – A Small Mass That Causes Lots Of Trouble (As Seen On House MD)
3. Parkinson’s Disease – 1 Out of 100 People Over Age 60