First examination (first row of images)

Clinical presentation: A 38-year-old woman was referred for evaluation of a newly diagnosed hypothyroidism and nodular goiter which were detected on evaluation of infertility.

Palpation: no abnormality.

Results of blood test: TSH 8.01 mIU/L, aTPO 308 U/mL.

Ultrasonography. The thyroid was echonormal. There were two hypoechogenic lesions in the right lobe, one in the middle and another one in the lower part. The former contained echonormal areas, as well, and has irregular shape and borders. This discrete lesion is doubtful whether being a true nodule or not. Regarding the lesion in the lower pole, this contained echogenic figures and had a more hypoechogenic pattern and also presented irregular shape. The categorization of this lesion is also equivocal, but this is more likely a true nodule than the lesion in the middle part of the lobe.

Aspiration cytology of both lesions resulted in Hashimoto's thyroiditis.

Suggestion: daily 50 microgram levothyroxine, repeat TSH in 3 months, repeat ultrasound in three years.

Second examination 3 years later (second row of images):

Clinical presentation: The patient had no complaints on daily 75 microgram levothyroxine. She has delivered a healthy child for 15 months.

Palpation: unchanged.

Result of blood test: TSH 1.90 mIU/L on daily 70 microgram levothyroxine.

Ultrasonography: Both the size and the pattern of the discrete lesions were unchanged. A moderately hypoechogenic area in the lower pole of the left lobe has appeared.

Suggestion: to continue with the replacement therapy. TSH-check in a year, in the event of pregnancy at once. Repeat ultrasound in 5 years.

Comments.

1. The only ultrasound sign of the underlying thyroiditis is the presence of two discrete hypoechogenic areas.

2. The lower lesion contains echogenic figures, therefore the likelihood being this lesion a true nodule is a bit greater compared with the other lesion.

3. The echogenic figures might be clusters of punctate echogenic foci (microcalcifications) or presentations of connective tissue.

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