Correspondence

Pemberton's Sign

N Engl J Med 2004; 351:196July 8, 2004

Article

To the Editor:

Basaria and Salvatori (March 25 issue) present superb photographs of a patient with Pemberton's sign in Images in Clinical Medicine.1 However, the accompanying computed tomographic (CT) scan of the thyroid gland appears to have been performed with the use of radiographic contrast material. The use of iodinated radiographic contrast agents may be contraindicated in patients with large goiters because of the risk of provoking iodine-induced hyperthyroidism and the subsequent difficulty in obtaining nuclear medicine images of the thyroid, if needed. We believe that non-contrast CT would have been a more appropriate means to study this patient.

Elizabeth N. Pearce, M.D.
Lewis E. Braverman, M.D.
Boston University Medical Center, Boston, MA 02118
elizabeth.pearce@bmc.org

1 References

1. 1

   Basaria S, Salvatori R. Pemberton's sign. N Engl J Med 2004;350:1338-1338
   Full Text | Web of Science | Medline

Author/Editor Response

Pearce and Braverman make an important point with regard to provoking iodine-induced hyperthyroidism in patients with large goiters. Because the majority of large goiters are multinodular (and have some nodules that function autonomously), excess iodine may be used as substrate for the synthesis and secretion of excess thyroid hormone (the Jod–Basedow phenomenon).1 This phenomenon, however, is more common in areas of the world where there is a deficiency of dietary iodine.2 On the basis of the presentation in our patient, we performed contrast-enhanced CT to heighten the delineation of the anatomy of the blood vessels of the neck. Furthermore, we agree that the administration of excess iodine, in any form, delays definitive radioiodine (iodine I-131) scanning, but we had previously decided to perform a total thyroidectomy in this patient. Hence, iodine I-131 therapy was not considered.

Shehzad Basaria, M.D.
Roberto Salvatori, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21224

2 References

1. 1

   Stanbury JB, Ermans AE, Bourdoux P, et al. Iodine-induced hyperthyroidism: occurrence and epidemiology. Thyroid 1998;8:83-100
   CrossRef | Web of Science | Medline

2. 2

   Martino E, Safran M, Aghini-Lombardi F, et al. Environmental iodine intake and thyroid dysfunction during chronic amiodarone therapy. Ann Intern Med 1984;101:28-34
   Web of Science | Medline

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