Initial examination (1st and 2nd rows of images):

Clinical presentation: A 50-year-old woman was referred for evaluation of fever and neck pain localized to the right lobe.

Palpation: The right lobe was painful and hard.

Laboratory examination: hyperthyroidism (TSH 0.01 mIU/L, FT4 43.4 pM/L), CRP 18.3 mg/L.

Ultrasonography: There were multiple hypoechogenic areas with ill-defined borders in both lobes, primarily in the right one. The vascularization was decreased.

Cytological diagnosis: subacute, granulomatous de Quervain's thyroiditis.

Suggestion. Steroid therapy and beta-blocking agent were administered. Within 24 hours of the administration of 32 mg methyl-prednisone, the neck complaints and subfebrility had stopped.

Examination 5 months later (3rd and 4th rows of images):

Clinical presentation: Within 24 hours of the administration of 32 mg methylprednisolone, the neck complaints and subfebrility had stopped and did not recur.

Palpation: The lobes were minimally tender.

Laboratory tests: minimal degree of hypothyroidism (TSH 4.08 mIU/L, FT4 11.5 pM/L), CRP 0.7 mg/L.

Ultrasonography: The thyroid decreased in size as did the extent of hypoechogenic areas. The vascularization was unchanged. There was a cystic lesion in the lower third of the right lobe. The solid part had microcalcification. We reviewed the video of the first examination and noticed that the lesion was already present, but it was much smaller. The difference in size was explained by the lack of cystic component at first investigation.

Cytology from the cystic lesion in the right lobe resulted in papillary carcinoma.

Total thyroidectomy was performed. Histopathology disclosed a papillary carcinoma. It was solitary with a 4 mm maximal diameter. The left lobe displayed no abnormality.

Comment. Sometimes it is better to overlook a lesion than to recognize it...