First examination (first two rows of images)

Clinical data: A 63-year-old woman came to a yearly follow-up examination because of a known thyroid nodule and a hypothyroidism replaced with daily 75 microgram levothyroxine. She had neck discomfort while turning her head to the right.

Palpation: There was a nodule in the left lobe.

Hormonal investigation indicated euthyroidism with TSH-level 1.01 mIU/L on daily 75 microgram levothyroxine. 

Ultrasonography revealed hypoechogenic inhomogeneous thyroid. There was a hyperechogenic nodule in the left lobe. The nodule presented a halo sign and perinodular blood flow. It increased in size, therefore we performed aspiration cytology.

Cytology: benign lesion.

X-ray examination excluded tracheal compression and disclosed neck rib. We offered rheumatological examination.

Second examination two years later (third row of images)

Clinical data: The complaints of the patient have worsened and she requested a repeat examination.

Palpation: unchanged.

Hormonal investigation indicated euthyroidism on daily 87.5 microgram levothyroxine (TSH-level 1.88 mIU/L). 

Ultrasonography was unchanged except for the increase of the left lobe by 38% in volume.

Cytology: benign lesion.

The patient was operated on because of compression signs.

Histopathology disclosed Hashimoto's thyroiditis and multiple hyperplastic nodules in the left lobe.

Comments.

1. It is worth comparing the numerous small echonormal lesions and the large nodule in the left thyroid. The formers are part of the so-called pseudonodular form of Hashimoto's thyroiditis, while the true nodule was much larger. Pseudonodules are usually in the range of 5 to 15 mm in maximal diameter.

2. This patient had a rare compression sign. We suppose that the nodule comprised a nerve while the patient turned her head to the right. This complaint was resolved after the surgery.

3. Most solitary nodules which are greater than 2 cm in maximal diameter and display a halo sign and perinodular blood flow are follicular tumor. This case belongs to the relatively rare exceptions.