First examination (first and second rows):

Clinical presentation: a 41-year-old woman was referred for an evaluation of complaints suggesting hyperthyroidism.

Palpation: both thyroids were enlarged and moderately firm.

Results of blood tests: hyperthyroidism (TSH undetectable, FT4 51.8 pM/L).

Ultrasonography: a diffusely hypoechogenic thyroid was found with multiple lesions, a hypoechogenic one in the right and two hyperechogenic nodules in the left lobe.

Cytology: was performed from the hypoechogenic nodule found in the right thyroid and from one of the hyperechogenic nodules in the left lobe.

Cytological diagnosis: benign pattern corresponding to hyperthyroidism.

TSAb was elevated 11.0 U/mL (normal value below 1.5) while scintigraphy excluded the possibility of autonomy.

Surgery was advised.

Follow-up examination 6 months later (third row):

Clinical presentation: the patient refused our suggestion and went on conservative therapy. She had no complaints.

Palpation: unchanged.

Results of blood tests: euthyroidism on daily 5 mg methimazole (TSH 1.17 mIU/L, FT4 17.2 pM/L).

Ultrasonography: except for a minimal decrease in hypoechogenicity and in the vascularization the pattern was unchanged.

TSAb was already elevated 8.7 U/mL (normal value below 1.5) while scintigraphy excluded the possibility of autonomy.

Follow-up examination 10 months after initial investigation (fourth row):

Clinical presentation: the original complaints of the patient recurred including 3 kg loss in weight and tachycardia.

Palpation: unchanged.

Results of blood tests: hyperthyroidism (TSH undetectable, FT4 47.5 pM/L).

Ultrasonography: the degree of hypoechogenicity and vascularization increased compared with previous investigation.

The dose of the thyrostatic was increased. 2 months later the patient underwent surgery.

Histopathology: diffuse goiter in both lobes and benign hyperplastic nodules in the left lobe.

Comment. It is worth analyzing the echo pattern of the thyroid. The small hypoechogenic area in the right lobe changed neither in size nor is shape nor in vascularization over 11 months.