hashimoto 's thyroiditis ( chronic autoimmune thyroiditis ) is the most common cause of hypothyroidism in the united states . with a 510 times preference over men ,
ht is an autoimmune disorder and is characterized by the presence of antithyroperoxidase ( anti - tpo ) antibodies .
a mixed population of lymphocytes , sometimes represented in the form of crushed lymphocytes and lymphoglandular bodies ( cytoplasmic debris ) together with the presence of hurthle cells , is characteristic cytological feature of hashimoto 's thyroiditis ( ht ) . till date ,
nowhere in the literature , a case of ht with four lobed thyroid gland has been reported , making our case an interesting and rare one .
a 40-year - old married woman came to the out - patient clinic of our institute with chief complaints of a progressively increasing swelling on the anterior aspect of the neck since last 9 months .
there was no history of any dysphagia , dyspnea , stridor , hoarseness of voice , fever or loss of weight .
on examination of the neck , there was a diffuse swelling on the anterior aspect of neck , nontender , firm , freely mobile horizontally but restricted mobility longitudinally .
ultrasonography of neck demonstrated thyromegaly with hypoechoic thyroid parenchyma and increased vascularity on color doppler imaging .
fine - needle aspiration cytology ( fnac ) of the swelling was advised which revealed features suspicious of follicular neoplasm .
contrast - enhanced computed tomography ( cect ) neck revealed diffuse enlargement of thyroid with lobulated appearance of both lobes and isthmus .
there was evidence of minimal tracheal compromise at isthmus level . however , there was no cect evidence of cervical lymphadenopathy .
serum levels of t3 , t4 , and tsh were 1.16 ng / ml ( n=0.82.0 ng / ml ) ; 6.5 milligram ( mg)/deciliter ( n=4.511.5 mg / dl ) , and 4.7 miu / l ( n=0.54.70 miu / l ) , respectively .
the patient was taken for surgery and intraoperatively , we found an unusual anatomy of thyroid gland consisting of four lobes .
the additional two lobes were on the antero - medial aspect of enlarged right and left main thyroid lobes and were completely separated from each other .
the gland was firm and was adherent posteriorly to trachea . due to the nonavailability of frozen section biopsy facility ,
histopathology of each of the four lobes showed hurthle cell changes with lymphocytic background , features suggestive of ht [ figure 2 ] .
thyroidectomy specimen showing four lobed thyroid gland with extra lobes ( 3 and 4 ) antero - medial to main ( 1 and 2 ) thyroid lobes histopathology of the thyroid specimen showing hurthle cell changes ( pink cells ) with lymphocytic background
ht is the most prevalent cause of subclinical or overt hypothyroidism in areas with sufficient iodine intake .
it has a peak incidence between the ages of 30 and 50 , and other autoimmune disorders may coexist with ht .
ht can present clinically as painless , firm diffuse goiter often accompanied by hypothyroidism and autoantibodies .
the clinical diagnosis is confirmed by low serum t4 levels , high thyroid - stimulating hormone levels , and the presence of autoantibodies to thyroglobulin and thyroid peroxidase .
it is not rare for patients with ht to have neither symptoms nor physical signs . in our case
also , the patient was asymptomatic and t3/t4 levels were within normal range with a slight increase in tsh levels ( subclinical hypothyroidism ) . if only clinical and serum findings were used to diagnose ht , the diagnosis would be missed in at least half of patients . since fnac was suspicious of follicular neoplasm , tests for autoantibodies to thyroglobulin and thyroid peroxidase were not performed in our case .
the sensitivity and specificity improve dramatically by combining ultrasound evaluation with clinical and serological assessments .
the most accurate method of diagnosing ht , however , remains biopsy and histologic study .
on sonography the gland is often diffusely enlarged , and the parenchyma is coarsened , hypoechoic , and often hypervascular .
a micronodular pattern on ultrasound is highly diagnostic of ht with a positive predictive value of 95% .
they are hypoechoic as a result of lymphocyte infiltration and have an echogenic rim . on color doppler , the thyroid parenchyma can vary from slightly hypervascular to markedly hypervascular .
in addition to the diffuse form , ht may form discrete nodules within a diffusely altered parenchyma or within a sonographically normal thyroid parenchyma ( nodular ht ) .
ours was a diffuse form of ht with two extra thyroid lobes completely separated from main lobes with increased vascularity .
such distorted anatomy of thyroid gland in a patient of ht has never been reported in the literature till date .
if we consider it as an anomaly of thyroid gland , again no literature has mentioned such an anomaly till date .
histopathology in ht shows infiltration of the thyroid by t and b cells that are reactive to thyroid antigens .
the cytotoxic t cells are largely responsible for the destruction of the thyroid parenchyma , leading to initial thyrotoxicosis followed by hypothyroidism . typical histopathologic appearance of ht includes lymphocyte aggregates with germinal centers , small thyroid follicles with sparse colloid , oxyphilic changes of epithelial cells , presence of hurthle cells and variable fibrosis . in our case , histopathology from all the four lobes showed hurthle cell changes with lymphocytic background , features suggestive of ht .
 hashimoto 's thyroiditis ( ht ) , an autoimmune disorder , is the most prevalent cause of subclinical or overt hypothyroidism in areas with sufficient iodine intake . 
 the gland is often diffusely enlarged , and the parenchyma is coarsened , hypoechoic , and often hypervascular on ultrasonograpy . 
 histopathologic appearance of ht includes lymphocyte aggregates with germinal centers , small thyroid follicles , presence of hurthle cells , and variable fibrosis . 
 we present a case of a 40-year - old female with suspected follicular neoplasm on fine - needle aspiration cytology of neck swelling . 
 intraoperatively , thyroid gland was found having four lobes separated from each other . 
 total thyroidectomy was done and histopathology from all four lobes revealed ht . 
 at present , there is no literature to support the fact that such distorted thyroid anatomy may be due to the underlying disease . 
 if we consider it as thyroid gland anomaly , no such anomaly has been mentioned in the literature till date . 
Introduction
Case Report
Discussion