Clinical presentation: A 33-year-old man was referred for follow-up of a nodular goiter. Aspiration cytology was performed from a cystic nodule located in the dorsal part of the left lobe 11 years ago. Cytology resulted in benign cystic degeneration.

Palpation: Both lobes were firm.

Laboratory tests: TSH 6.49 mIU/L, aTPO 773 U/mL.

Ultrasound. Both lobes were moderately hypoechogenic. There were two hypoechogenic lesions, one in the ventral part of the right lobe while another one in the upper part of the left lobe. There were similarly hypoechogenic, smaller areas elsewhere in the thyroid. There was no discrete lesion corresponding to the nodule aspirated 11 years ago.
The lesion in the right lobe was doubtful being a nodule in pathological sense. The left circumscribed area was probably not a nodule in pathological sense.

Aspiration cytology was performed from both lesions and resulted in Hashimoto's thyroiditis.

Suggestion: repeat TSH in 6 months.

Follow-up 6 months later. The TSH returned to normal (3.82 mIU/L). We suggested TSH determination every year while ultrasound in 5 years.

Comment. Except for women in childbearing age and in patients with enlarged thyroids, we initiate replacement therapy in a patient free of complaints if the TSH is even once above 8 mIU/L or repeatedly above 5 to 6 mIU/L.