Summary and comments
44 participants have answered the questions.
1. Does the right lobe have pathological nodule?
Distribution of answers
Choice
Percentage
No
Yes, the dorsal one is very likely a true nodule.
9.1%
4
Yes, there are probably more nodules in the right lobe.
4.5%
2
No, the discrete lesions correspond to more active foci of thyroiditis.
86.4%
38
Expert comment
I agree with most of the colleagues. None of the lesions correspond to true nodules.
2. Which is the most likely diagnosis?
Distribution of answers
Choice
Percentage
No
Nodular goiter.
0%
0
Hashimoto's thyroiditis.
11.4%
5
Subacute, de Quervain's thyroiditis.
79.5%
35
Nodular goiter and any form of thyroiditis.
9.1%
4
Expert comment
If we consider the complaints and the ultrasound presentation, it is evident that this patient has thyroiditis. Regarding the presence of true nodule or nodules, I refer to my previous comment.
Some of the data (mainly the symptoms) are in favor of de Quervain thyroiditis. However, ultrasound imaging (the borders of the discrete lesions are sharp and not blurred and present vascularity) is much more likely to suggest Hashimoto's thyroiditis. Considering that cervical tenderness and fever also occur in the case of Hashimoto, and that the circumscribed areas are not always blurred and avascular in the case of de Quervain, it is ultimately impossible to decide between the two forms on the basis of the data available at the time of the study. However, there is one more argument which favors Hashimoto's thyroiditis and this is the presence of hypoechoic areas in the left lobe. It is not a conclusive argument, but in the case of de Quervain thyroiditis it is relatively rare to see this picture on the non-complainant side two weeks after the complaints have been reported.
3. What diagnostic test or tests would you indicate?
Distribution of answers
Choice
Percentage
No
FNA from the largest hypoechoic lesion in the right lobe.
2.27%
5
TSH (FT4 and FT3)
77.2%
34
Anti-TPO
52.3%
23
CRP
88.6%
39
Expert comment
I'm sure the 10 colleagues who wouldn't have indicated TSH did so because they didn't realize they could have given multiple answers. (All 10 entered only one answer.)
I think all three exams except the FNA are clearly justified and necessary. If the results would be inconclusive, then FNA would be also of great help.
At the same time, there are arguments in favor of the FNA being carried out immediately. On the one hand, this intervention involving blood collection discomfort is more sensitive to detecting de Quervain's thyroiditis as soon as it is performed after the onset of symptoms. It is also worth considering individual aspects when making a decision. These include the availability of the cytopathologist and, for example, the burden on the patient of a repeated appearance; the patient lives two minutes from the office or has to travel for hours.
4. If you would consider the largest lesion in the dorsal part of the RIGHT lobe as nodule, how to categorize it according to EU-TIRADS?
Distribution of answers
Choice
Percentage
No
EU-TIRADS 3
6.8%
3
EU-TIRADS 4
31.8%
14
EU-TIRADS 5
61.4%
27
Expert comment
The dorsal hypoechoic lesion is moderately hypoechoic but has lobulated margins. Therefore, is should be regarded as an EU-TIRADS 5 lesion if we would consider it as true nodule.
