Book Review

Thyroid Disease in Clinical Practice

N Engl J Med 1993; 328:1648-1649June 3, 1993

Article

Thyroid Disease in Clinical Practice
By I. Ross McDougall. 332 pp., illustrated. London, Chapman and Hall, 1992. £55. ISBN: 0-412-35130-7

The thyroid gland has been in the news in the past few years, with both former President George Bush and Barbara Bush given a diagnosis of Graves' disease. Although conjugal thyrotoxicosis (perhaps now dignified with the eponym “Bush disease”) has no clear cause -- though shared stress in genetically predisposed persons is as likely a candidate as any -- and is quite uncommon, it does behoove the internist to be aware of the increased risk of autoimmune disease, especially that involving the thyroid, in the offspring of patients with Graves' disease.

In the general population, thyroid-gland dysfunction is relatively common at all ages. In the neonate, the frequency (1 per 4000) is three times that of phenylketonuria, and the consequences of diagnostic failure are just as disastrous. Frank hypothyroidism occurs in at least 3 percent of the population over the age of 60 years, but an elevated serum level of thyrotropin may be present in another 6 to 9 percent on the basis of population screening. Should all these patients be treated? No definitive answer is available regarding the care of the asymptomatic elderly patient with a borderline elevation in serum thyrotropin, and different thyroidologists will make different recommendations. Thyroid nodules occur in up to 7 percent of the adult population, and 10 percent of these are malignant. How should these cases be approached and managed?

These common issues clearly illustrate the fact that thyroid disease confronts the busy internist on a daily basis. Where should he or she turn for guidance? Although some patients need to be referred to an endocrine specialist, others can readily be cared for by the generalist. The thyroid sections in general textbooks of medicine often do not fully address the practical management issues. Other textbooks, such as Werner and Ingbar's The Thyroid, edited by L.E. Braverman and R.D. Utiger (6th ed. Philadelphia: J.B. Lippincott, 1991), are fine for the thyroid aficionado but can be daunting when the answer to a single question is being sought. Dr. McDougall, who is a professor of radiology and medicine at Stanford, has a wealth of experience in the investigation and management of thyroid disease, and this clearly shows in the textbook he has written, Thyroid Disease in Clinical Practice. It is not often nowadays that textbooks are written by a single author, and it is refreshing to read one with all the advantages afforded by evenness of style. The book is conveniently organized, with initial chapters on anatomy and embryology, physiology, thyroid-function tests, and clinical examination. These are followed by an orderly review of hyperthyroidism and hypothyroidism, thyroid nodules, cancer, and thyroiditis. A valuable feature at the end of each chapter is a section entitled “Key Facts,” which succinctly summarizes the “take-home message.”

As with all textbooks, it is possible to find errors or omissions. A discussion of the role of thryotropin-releasing hormone testing states that thyrotropin-releasing hormone does not cause an increase in growth hormone in acromegaly. However, such a paradoxical response occurs in 50 percent of patients with acromegaly and is diagnostically useful in monitoring the response to treatment.

Familial dysalbuminemic but not dysprealbuminemic hyperthyroxinemia is discussed as a cause of an elevated thyroxine level in a person with euthyroidism. Although it is acknowledged that persons with hypothyroidism are thought to have a bleeding tendency (acquired von Willebrand's disease), the author believes that this is rarely a clinical problem. It should be recognized, however, that aspirin therapy for coronary heart disease can lead to serious and life-threatening hemorrhage in a patient with hypothyroidism. I do sympathize with the plea that thyroid scans be performed with iodine-123 rather than technetium-99m, since the latter occasionally shows a nodule to be “hot” when the former indicates that it is “cold.” Unfortunately, the issue is one of economics. Iodine-123 has a short half-life (12 hours), and if a patient does not show up for a scan, it cannot readily be reused for someone else the next day.

These criticisms, however, should not detract from the overall merit of this book. Internists who are interested in the management of thyroid disorders will find it helpful to keep this textbook handy.

Ivor Jackson, M.D.
Rhode Island Hospital, Providence, RI 02903