First examination (1st and 2nd rows of images)

Clinical presentation: a 35-year-old woman was referred for evaluation of a hypothyroidism diagnosed 4 months after delivery. The TSH was 4.34 mIU/L, and daily 25 microgram levo-tiroxin was administered.

Palpation: no abnormality.

Functional state: euthyroidism on daily 25 microgram levo-tiroxine with TSH-level 0.83 mIU/L. Anti-TPO was normal (0.3 U/mL).

Ultrasonography: the thyroid was echonormal. There was a minimally hypoechogenic nodule in the lower pole of the right lobe. The nodule displayed halo sign and a type 2 vascular pattern.

Cytology was performed and resulted in follicular tumor without significant atypia.

A combined clinical-ultrasound-cytological diagnosis was suspicion of a follicular tumor with less than 1% risk of carcinoma.

The patient decided to undergo follow-up instead of immediate surgery. The levo-tiroxine therapy was stopped.

Second examination 3 years later (3rd row of images)

Summary of follow-up: the patient underwent yearly ultrasound and TSH examination. The nodule was unchanged, he had no complaints.

Functional state: euthyroidism with TSH-level 1.22 mIU/L.

Ultrasonography: the ultrasound presentation of the thyroid was unchanged.
The volume of the nodule was 0.31 and 0.35 mL, at the first examination and at the 3-year follow up, respectively.

Suggestion: to continue the follow-up with ultrasound and TSH determinations every year.

Comment.

We not infrequently find a slightly elevated TSH level within the first year after delivery. There are two possibilities. First, the patient has an underlying autoimmune thyroiditis which is more active within the first year after a labor, and even extremely high TSH levels can be normalized in this period. Second, that the thyroid is healthy and the TSH elevates because the need for thyroid hormones is increased in this life period.