First examination (1st row of images)

Clinical presentation: a 60-year-old woman was referred for a follow-up investigation. She has been known to have a nodule in the left lobe for 7 years. She had 'lump in the throat' feeling.

Palpation: a nodule in the left lobe.

Functional state: euthyroidism (TSH-level 2.95 mIU/L).

Ultrasonography: the right thyroid was intact. There was a hypoechogenic nodule in the left lobe. Compared with the formed examination the nodule increased in volume by 38%.

Cytological diagnosis: benign colloid goiter.

Second examination 3 weeks later (2nd and 3rd rows of images)

Clinical presentation: the patient told that her right thyroid became painful and she had fever. Her complaints began for 3 days. Her GP administered antibiotics but her complaints were unchanged.

Palpation: the whole left thyroid was hard and painful.

Laboratory tests: granulocytosis (11 G/L) and elevated CRP level (23.8 mg/L).

Ultrasonography: the thyroid was unchanged except for increase in size of the nodule in the left lobe. The lesion became cystic and contained multiple hyperechogenic granules corresponding to protein-rich structures. A type 1 vascular pattern was found.

We aspirated 5 ml purulent cystic fluid. Cytological diagnosis: acute infllammation.

We changed the antibiotics.

Third examination 1 week later (4th row of images)

Clinical presentation: the patient had no complaints.

Palpation: the thyroid was painless but already very firm.

Laboratory investigation: granulocytosis and CRP level decreased, 9.6 G/L and 10.7 mg/L, respectively.

Ultrasonography: the nodule became smaller and the cystic part has not refilled.

Fourth examination 30 month after the initial examination (5th row of images)

Clinical presentation: the patient had no after the previous examination. We met her three times. Laboratory tests remained normal.

Palpation: no abnormality.

Functional state: euthyroidism (TSH-level 2.71 mIU/L).

Ultrasonography: the thyroid was echonormal. Corresponding to the previously inflamed nodule, there was a much smaller hyperechogenic lesion in the left lobe.

Comments.

1. We performed more than 43,000 FNAC-s, it means around 150,000 punctures of thyroid. Three cases occurred when 1 to 3 weeks after the examination the patient presented acute inflammation.

2. Note the hyperechogenic, protein-rich structures at the time of acute inflammation.

3. Naturally, this case is not a true purulent thyroiditis, because only the nodule presented the signs of inflammation while the extranodular thyroid remained intact.

4. Although the patient suffered a painful disease, this attack had the advantage that her nodule decreased significantly in size thanks to the inflammation.