Right lobe

Left lobe

First examination (first and third rows of images)

Clinical presentation: A 41-year-old woman was referred for evaluation of a newly discovered hypothyroidism and a suspicious nodule.

Palpation: no abnormality.

Results of blood test : TSH 13.1 mIU/L, aTP0 above 1300 U/mL.

Ultrasonography. The thyroid was moderately hypoechogenic and presented several more hypoechogenic areas which had not regular, geometrical shape. There was a relatively large hypoechogenic lesion in the lower central part of the left lobe. This lesion presented both echogenic lines and granules. This lesion was described as suspicious on previous ultrasound report.

Aspiration cytology from the lesion in question resulted in Hashimoto's thyroiditis.

Suggestion: daily 75 microgram levothyroxine.

Second examination 23 months later (second and fourth rows of images)

Clinical presentation: The patient had no complaints.

Palpation: no abnormality.

Result of blood test: TSH 2.37 mIU/L on daily 100 microgram levothyroxine.

Ultrasonography. The pattern of the thyroid remained unchanged.

Suggestion: To continue with daily 100 microgram levothyroxine.

Comment. Bright hyperechogenic granules can be easily misinterpreted as microcalcifications if we overlook the synchronous presence of echogenic lines. The synchronous presence of echogenic granules and lines is the hallmark of connective tissue.