THYROIDVolume 13, Number 10, 2003© Mary Ann Liebert, Inc.

Images in Thyroidology*

Section Editor: Yaron Tomer

An Unusual Case of Marine-Lenhart Syndrome

S. El-Kaissi,1 M.A. Kotowicz,1 M. Goodear,2 and J.R. Wall1

993

A53-YEAR-OLD MAN presented with hyperthyroidism (freethyroxine [FT4] 32.3 pmol/L [range, 9.0–26.0], free tri-

iodothyronine [FT3] 14.7 pmol/L [range, 2.4–5.4], and thy-rotropin [TSH] 0.005 mU/L [range, 0.30–5.0]) and ophthal-mopathy. He had a diffuse goiter with palpable enlargementof the left lower lobe, bilateral proptosis (20–22 mm) and re-duced convergence.

Serum thyrotropin-receptor antibody was normal at 14units (range, 215–15), whereas thyroid peroxidase (. 1000IU/mL; normal, , 40) and thyroglobulin (. 3000 IU/ml;normal, , 40) antibodies were elevated. Ultrasound showeda diffusely enlarged gland with no nodularity and diffuselyincreased Doppler color flow (Fig. 1).

99mTc thyroid nuclear scan showed asymmetrical uptakewith a hot nodule in the left lower lobe and relative sup-pression of the remaining gland (Fig. 2). Overall uptake wasincreased at 9.6% (normal, 2%–5%) and lobar uptakes were:left lower 49.5%, left upper 13.2%, right lower 24%, right up-per 11.5%, and isthmus 1.8%. Orbital computed tomography(CT) showed mild proptosis and bilateral enlargement of theextraocular muscles, in particular the superior and inferiorrecti (Fig. 3).

This case illustrates the coexistence of an autonomouslyfunctioning thyroid nodule (AFTN) and Graves’ disease,known as Marine-Lenhart syndrome, associated with oph-thalmopathy. The increased radionuclide uptake in the

1Department of Clinical and Biomedical Sciences, Barwon Health, The Geelong Hospital, Geelong, Victoria, Australia.2Geelong Radiology Clinic, Geelong, Victoria, Australia.

*If you would like to submit an image for publication in “Images in Thyroidology” please send two copies of high-quality black-and-white images with a short legend. In special circumstances color figures will be published. Please inquire with the Section Editor for de-tails. All material must be original and neither published nor submitted elsewhere. The legend should give relevant clinical information.The entire legend should be typed double-spaced, and should be no more than 200 words. Send all submissions to Yaron Tomer, M.D.,Box 1055, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029; E-mail: Yaron.Tomer@mssm.edu

FIG. 1.

AFTN is unusual and may reflect a high degree of TSH-in-dependence.

The patient was treated with carbimazole and subse-quently received radioiodine therapy.

References

1. Carnell N, Valente W 1998 Thyroid nodules in Graves’ dis-ease: Classification, characterization and response to treat-ment. Thyroid 8:571–576.

2. Carnell N, Valente W 1998 Thyroid nodules in Graves’ dis-ease: Classification, characterization and response to treat-ment. Thyroid 8:647–652.

3. Charkes ND 1972 Graves’ disease with functioning nodules(Marine-Lenhart Syndrome). J Nucl Med 13:885–892.

4. Nishikawa M, Yoshimura M, Yoshikawa N, Toyoda N,Yonemoto T, Ogawa Y, Mori S, Tabata S, Tokoro T, Sakaguchi

IMAGES IN THYROIDOLOGY994

N, Inada M 1997 Coexistence of an autonomously function-ing thyroid nodule in a patient with Graves’ disease: An un-usual presentation of Marine-Lenhart Syndrome. Endocr J44:571–574.

Address reprint requests to:J.R. Wall

Department of Clinical and Biomedical SciencesBarwon Health

The Geelong HospitalPO Box 281

Geelong, Victoria, 3220Australia

E-mail: bawonhealth.org.au

FIG. 2.

FIG. 3.