First examination (first row of images)

Clinical presentation: a 27-year old woman was investigated because of headache. The GP initiated including others a thyroid examination. The patient had no complaints suggestion thyroid disorder.

Palpation: no abnormality.

Hormonal examination: indicated euthyroidism (TSH 1.68 mIU/L).

Ultrasonography: the right thyroid was echonormal and presented small punctate hypoechogenic areas while the left lobe was minimally hypoechogenic. The echogenicity index was around 5%.

An anti-TPO test resulted in normal value (1 U/mL) as did anti-hTg (0 U/mL).

We suggested TSH determination every two years, in the event of pregnancy at once.

Second examination 17 months later (second row of images)

Clinical presentation: the patient visited us because she became pregnant. She was on 5th week of pregnancy and except for nausea had no complaints.

Palpation: no abnormality.

Ultrasonography: compared with the previous investigation the hypoechogenic areas increased in size. The echogenicity index was around 15%.

Hormonal examination: subclinical hypothyroidism (TSH 4.07 mIU/L, FT4 13.8 pM/L). Compared with the previous examination anti-TPO became higher (71 U/mL) but was already in the normal range.

Daily 50 microgram levo-tiroxin was administered. The TSH was checked 6 weeks later and resulted in 0.84 mIU/L. Thereafter 3 months later was a repeat TSH-determination (7.08 mIU/L) when the dose of levothyroxine was increased to 75 microgram. Two weeks after delivery the replacement therapy was stopped. Now, 2 years later the patient is euthyroid.

Comments.

1. There is a continuous debate in the literature as to whether a patient with a high normal TSH has to be treated or not, i.e. when the TSH is between 2.5 mIU/L and the upper normal value. I do not discuss here this issue. My practice is the described elsewhere. The pivotal feature is the demonstration of an underlying autoimmune thyroiditis.

2. On my experience, ultrasound is more sensitive than anti-TPO in the detection of mild degree of autoimmune thyroiditis. This case study supports this opinion.

3. It is worth to compare this case study with the previous one.