Clinical presentation: A 66-year-old hypothyroid woman was referred for follow-up examination of a nodular goiter. Aspiration cytology resulted in benign follicular proliferation and lymphocytic thyroiditis three years ago. She was treated for hypothyroidism for more than 10 years.

Palpation: a moderately firm nodule in the right lobe.

Hormonal investigation: hypothyroidism on daily 75 microgram levothyroxine (TSH 8.02 mIU/L). The aTPO was above 1000 U/mL 3 years ago.

Ultrasonography. The thyroid was minimally-moderately hypoechogenic. There was moderately hypoechoic nodule presenting halo sign and both intranodular and perinodular blood flow in the right lobe. The left lobe was minimally hypoechogenic and had several discrete lesions. The size of the nodule in the right lobe did not change over the past three years.

Suggestion: daily 100 microgram levothyroxine.

Comment. At first glance the nodule seemed more echogenic than the extranodular part to me. Thereafter, I have measured the histogram values, and the nodule proved to be less echogenic: see footnote to the first image.