Clinical presentation: A 36-year-old woman was referred for evaluation of an elevated TSH (5.08 mIU/L) detected on routine blood test 2 months ago. She had no complaints. The height of the patient was 161 cm while the weight was 42 kg.

Palpation: a moderately firm nodule in the right lobe.

Functional state: euthyroidism with TSH 2.18 mIU/L, FT4 14.3 pM/l, aTPO 0 U/mL.

Ultrasonography. The thyroid was echonormal. There was a cystic nodule in the right lobe. The solid part of the lesion contained various hyperechogenic granules and lines. The vascularization was increased.

Cytology resulted in benign cystic-colloid goiter.

Comments.

1. The cause for elevated TSH remains unclear. There were no signs of an underlying thyroiditis, neither the ultrasound nor the aTPO nor the cytology suggested autoimmune thyroiditis. On the other hand, the physique of a patient has a well-known impact on the normal value of TSH, thinner the build higher the upper level of TSH.

2. At first sight, the two bright hyperechogenic granule presented in the transverse scan of the right lobe seems to be difficult to categorize. However, the less bright granules and the synchronous presence of hyperechogenic lines are signs of back wall figures or connective tissue. Therefore, the bright granules belong very likely even to this subgroup.