First examination (first row of images)

Clinical data: A 14-year-old girl was referred for evaluation of a goiter discovered on school screening.

Palpation: Both lobes were firm and enlarged.

Laboratory evaluation: TSH-level 2.67 mIU/L, aTPO 601 U/mL. 

Ultrasonography revealed hypoechogenic inhomogeneous thyroid. There were several discrete echonormal and less hypoechoic discrete lesions. Most corresponded to those parts od the thyroid which were not or less influenced by the underlying thyroiditis. One of them in the ventral part of the left lobe could be a pathological nodule. The volume of the thyroid was 38.7 mL.

Suggestion: considering the enlargement of the thyroid, 25 microgram levothyroxine was adjusted.

Second examination three years later (second row of images)

Clinical data: The patient had no complaints.

Palpation: unchanged.

Laboratory evaluation: TSH-level 1.18 mIU/L on daily 25 microgram levothyroxine. 

Ultrasonography. The pattern did not change except that the size of the lobes became smaller. The volume of the thyroid was 30.0 mL.

Suggestion: taking 25 micrograms of levothyroxine daily. Ultrasound after three years.

Comments.

1. Although, we can neither exclude nor justify that the lesion in the ventral part of the left lobe is a true nodule. In such cases, the term nodule-like or discrete lesion is clearly preferred over nodule.

2. We rarely apply levothyroxine in euthyroid Hashimoto's patients. The exception is the diffuse enlargement in children or young adults.