First examination (first row of images)

Clinical presentation: A 34-yr-old woman was referred for evaluation of a nodular goiter discovered on ultrasound examination. She had been suffered from mild neck discomfort in the right side of the neck and from subfebrility for 5 weeks when she visited her GP. Three days later at the time of ultrasound examination her complaints were ceased. A suspicious nodule having blurred borders and microcalcifications was described in the left lobe. We met the patient another week later when. At this time, her left thyroid region was tender, and she had again subfebrility.

Palpation: Both lobes were hard, and the left was painful on palpation.

Result of blood tests: TSH 4.08 mIU/L, aTP0 447 U/mL, CRP 28.3 mg/L (normal value < 5).

Ultrasonography.  The right lobe presented numerous while the left did one relatively large hypoechogenic area. The lesions in the right lobe were relatively well-demarcated while the lesion in the left lobe had blurred borders. The pale echogenic figures within this lesion did not fit to microcalcifications. The vascularization was average according to the hypoechogenic areas. There was an isoechoic lesion having halo sign and perinodular blood flow at the middle-lower part of the left lobe.

Aspiration cytology was performed from the hypoechogenic lesion in the left lobe and resulted in subacute granulomatous de Quervain's thyroiditis.

Suggestion: methylprednisolone therapy for 6 weeks starting with daily 32 mg. The complaints of the patient have ceased promptly and had not recurred.

Second examination 3 months later (second row of images)

Clinical presentation: The endocrinologist indicated a follow-up examination at the 19th week of pregnancy.

Palpation: Both lobes were firm but not tender.

Result of blood tests: TSH 2.13 mIU/L, FT4 14.7 pM/L.

Ultrasonography. The hypoechogenic areas had significantly decreased.

Suggestion: repeat examination in 6 months, in the event of complaints at once.

Third examination 36 months later (third row of images)

Clinical presentation: The patient had no complaints after ceasing the steroid therapy. Her thyroid function remained normal.

Palpation: Both lobes were firm and not tender.

Result of blood tests: TSH 2.060 mIU/L, aTPO 701 U/mL.

Ultrasonography. The echogenicity index has significantly increased, it was around 30 to 40%. The isoechoic nodule in the left lobe remained unchanged.

Suggestion: TSH determination every year.

Comments.

1. Except for the isoechoic lesion in the left lobe, which is very likely a nodule in pathological sense, no other lesions were true nodules.

2. The patient had three different entities: subacute and chronic thyroiditis and nodular goiter.

3. It is interesting that the extent of hypoechogenicity was as high at the time of painful thyroiditis as at the 3-yr follow up when the patient had no complaints. Moreover, the two types of thyroiditis affected the same parts of the thyroid. (In most if not all of de Quervain's patients the thyroid becomes echonormal within 2 years after the onset of the painful attack.)

4. The categorization of the isoechoic nodule in the left lobe depends on the definition of normal thyroid. If it is the extranodular part than the nodule is iso/hyperechoic. If the reference tissue is the healthy thyroid than the nodule is minimally/moderately hypoechoic because the histogram value of the nodule (56.0) is lower than that of the healthy thyroid (82.0).