Thyroid nodules are very common, occurring in up to 65% of the population. However, they are most commonly benign (up to 95%) and discovered incidentally. There is a substantial occurrence of thyroid nodules in countries or areas with iodine-depleted soil, and it occurs more commonly in women, increasing in incidence with advanced age and body mass.  

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CC: Thyroid Nodule 

Paula was 63 years old when she first presented with concerns about a new lump in her neck. She initially chalked it up to an enlarged lymph node after being sick with an upper respiratory infection a few weeks prior. However, she scheduled a visit after it did not go away when her symptoms did. 

Her thyroid palpation revealed a small mass on her left thyroid lobe that was small, well-demarcated, and non-mobile. It was not tender with direct palpation of the area but was causing her significant anxiety as her grandfather passed from thyroid cancer in his 80s. 

She was sent for a thyroid ultrasound, which showed a well-defined mass measuring 4.5 mm. She was not showing any signs of it being a questionable lesion. Therefore, we were free to treat. 

Additional History

Overall, Paula lived a clean, healthy lifestyle, mainly eating home-cooked meals consisting of whole foods, fruits and vegetables, and plant and animal-based protein, with the recent addition of fermented dairy following an osteopenia diagnosis a few months prior. She was also recently encouraged to exercise more, and she was doing pilates 2-4x a week and walking a few miles on the days she was not in pilates. She ate fish 1x monthly when going out to dinner but never at home.

She was an empty nester and worked part-time, three days a week. Stress was very low and well managed, and she prioritized sleep, getting 8-9 hours nightly. She had no history of thyroid issues and denied the classic symptoms of fatigue, constipation, anxiety, dry skin/hair, hair loss, or brittle and breaking nails. She took fish oil and magnesium glycinate daily but no other medications and had no diagnosed conditions. 

One significant factor likely affecting Paula's nodule development was her location. She lived in southeast Michigan, and the midwest states are notorious for having iodine-depleted soil. She purchased much of her produce from a local farmer's market, meaning she was likely eating foods depleted of this nutrient. 

Initial Lab Work

A Skin Iodine Patch Test was also done as the patient did not want to do the Iodine Excretion Test (a 24-hour urine collection test). The Skin Iodine Patch Test is when a 2% iodine solution is "painted" on the patient's wrist. A person with adequate iodine should have the iodine patch for at least 24 hours. In Paula's case, the patch was gone 8 hours later, indicating an iodine deficiency. 

Lab Analysis 

Paula's lab work points to low iodine, one of the main driving factors for thyroid nodule development. Her other minerals used in high amounts by the thyroid were also on the low end, as seen with her functionally low zinc and selenium. Her thyroid panel and antibodies were normal and within range, indicating no hypothyroidism. 

The gold standard for iodine evaluation is a 24-hour urine collection following an iodine load test. However, the patient opted out of this and preferred the blood test, so we added the iodine skin patch to evaluate iodine in two ways. In Paula's case, the lab value was low, and the iodine patch test revealed a deficiency, with it disappearing long before the 24-hour mark. 

Interventions

• Mineral Supplement: consisting of zinc, selenium, manganese, chromium, and boron to support functionally low levels. 
• Iodine in the form of liquid potassium iodide at 75 mcg 1x daily. She was also encouraged to eat iodine-rich foods daily: oysters, canned salmon, free-range organic eggs, sushi with seaweed, and seaweed/nori.  
• She was recommended a quality water filter and shower filter as fluoride exposure from tap water is linked to increased incidences of hypothyroid, as fluoride will compete with iodine for absorption.  
• She was also told to limit raw goitrogens, which can prevent the utilization of iodine by the thyroid. These are broccoli, kale, Brussels sprouts, cauliflower, rutabaga, cabbage, turnips, soybeans, peanuts, and pine nuts. 
• Discussed clean living and opting for organic food and an indoor air purifier to reduce PCB and PBB exposure (polybrominated and polychlorinated biphenyls), which can also negatively affect the thyroid. 
• Thyroid Castor Oil Pack was recommended 3x weekly for 30 minutes. This is an easy way to support blood flow to the thyroid to enhance nutrient delivery and support profusion. 

Follow-Up 3 Months Later

Iodine Skin Patch Test at 3-Month Follow-Up

The iodine patch remained for 22 hours. 

Follow-Up Interpretation

At our follow-up visit three months later, Paula was pleasantly surprised at her increased energy level, and her skin and hair also looked shiny and supple. Her labs indicated improvement in all her nutrient levels with the support of diet and supplements, and she was told to reduce the minerals to 3x weekly. 

We also reviewed foods high in zinc, selenium, magnesium, and iodine again to ensure she could keep up with nutrient intake in place of the supplement. She was also told to continue the iodine supplement 3x weekly.

6-Month Follow-Up

Paula insisted on repeating the thyroid ultrasound as she could no longer feel the lump and wanted to see if it was gone. She reported that she was delighted that the nodule had shrunk to 1.2 mm and was barely visible on the ultrasound. 

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Summary

Not all thyroid nodules are so quick to respond to treatment. However, Paula's case was unique because she already had the basic foundation of a healthy diet and active lifestyle. This case also points to the fact that a person can eat all the fruits and vegetables and still suffer from nutrient deficiencies, expressing the importance of lab testing to evaluate.