Clinical presentation: A 66-year-old man was referred for a second opinion. A suspicious nodular goiter was described on carotid Doppler examination followed by aspiration cytology which resulted in follicular tumor. The patient has been treated for hypothyroidism for 15 years.

Palpation: The right lobe was firm and had an uneven surface.

Laboratory test: TSH 1.33 mIU/L on daily 100 microgram levothyroxine.

Ultrasound. The thyroid was echonormal and presented several hypoechogenic areas. The echogenicity index was above 70%. The lesion in question was located in the lower part of the right lobe. It had irregular, puzzle-like borders and had punctate echogenic foci. The lesion presented neither a halo nor perilesional blood flow. The lesion had some echogenic figures which could be punctate echogenic foci. There were other, similar discrete lesions elsewhere in the thyroid.

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

We suggested follow-up instead of surgery. The patient decided to go on lobectomy.

Histopathology disclosed Hashimoto's thyroiditis without any nodules.

Comment. The ultrasound presentation of the lesion is edifying. The irregular borders in the event of Hashimoto's thyroiditis have minimal relevance, a puzzle-like border even stands against papillary carcinoma and stands for thyroiditis. The punctate echogenic foci clearly raised the possibility of papillary carcinoma. On the other hand, this lesion is hardly could be a follicular tumor which must have capsule.