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nephritis with primary tubular lesions associated with antibasement membrane antibodies If the intradermal test described below is negative, desensitization is not necessary, and a full dose of the material may be given If the test is positive, alternative drugs should be strongly considered If that is not feasible, desensitization is necessary Patients with a history of allergy to penicillin are also at an increased risk for having a reaction to cephalosporins Since the specific immunogens responsible for anaphylaxis are not known for drugs other than penicillin, skin testing with cephalosporins is not recommended A common approach to these patients is to assess the severity of the reaction If an IgE-mediated reaction to penicillin can be excluded by history, a cephalosporin can be administered When the history justifies concern about an immediate-type reaction, penicillin skin testing should be performed If the test is negative, a cephalosporin can be given If the test is positive, there is a 5 10% chance of cross reactivity, and cephalosporin desensitization should be performed

Radioactive 131I is a treatment option for hyperthyroid patients with toxic thyroid adenomas, multinodular goiter, or Graves disease (see Hyperthyroidism section) It may also be used to shrink benign nontoxic thyroid nodules Thyroid nodules shrink an average of 40% by 1 year and 59% by 2 years after 131I therapy Nodules that shrink after 131 I therapy generally remain palpable and become firmer; they may develop unusual cytologic characteristics on FNA biopsy Hypothyroidism is a risk and may occur years after 131 I therapy, so thyroid function testing must be performed regularly

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Patients with elevated levels of serum TSH are treated with levothyroxine replacement Otherwise, for small benign thyroid nodules, levothyroxine suppression therapy is not required For larger nodules (> 2 cm), if TSH levels are elevated or normal, suppression with levothyroxine (starting doses of 50 mcg daily) can be considered Levothyroxine should not be administered if the baseline TSH is low, since that is an indication of autonomous thyroid secretion, such that levothyroxine therapy will be ineffective and liable to cause clinical thyrotoxicosis Long-term levothyroxine suppression of TSH tends to keep nodules from enlarging, but only a few will actually shrink In one 5-year study, thyroid nodule size increased in 29% of patients treated with levothyroxine, compared to growth in 56% of nodules in patients not receiving levothyroxine Levothyroxine suppresssion also reduces the emergency of new nodules: 8% with levothyroxine and 29% without levothyroxine Levothyroxine suppression needs to be carefully monitored, since it carries a 17% risk of inducing symptoms of hyperthyroidism This can occur due to excessive levothyroxine dosing, the emergence of an autonomous or toxic nodule or Graves disease, or a reduction in thyroid binding globulin seen in early menopause or with discontinuing oral estrogen therapy Therefore, levothyroxine suppression

The great majority of thyroid nodules are benign Benign thyroid nodules may involute but usually persist or grow slowly About 90% of thyroid nodules will increase their volume by 15% over 5 years; cystic nodules are less likely to grow Cytologically benign nodules that grow are unlikely to be malignant; in one series, only 1 of 78 rebiopsied nodules was found to be malignant The prognosis for patients with thyroid nodules that prove to be malignant is determined by the histologic type and other factors (see below) Multinodular goiters tend to persist or grow slowly, even in iodinedeficient areas where iodine repletion usually does not shrink established goiters Patients with very small, incidentally discovered, nonpalpable thyroid nodules do require follow-up with thyroid ultrasound but are at low risk for malignancy Nodules that are malignant have a minor effect on morbidity and mortality

Bui A et al New paradigms in the diagnosis and management of thyroid nodules Endocrinologist 2007;17:35 Heged s L Clinical practice The thyroid nodule N Engl J Med 2004 Oct 21; 351(17):1764 71 [PMID: 15496625] Kang HW et al Prevalence, clinical and ultrasonographic characteristics of thyroid incidentalomas Thyroid 2004 Jan;14(1): 29 33 [PMID: 15009911]

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