Marine Lenhart syndrome

Marine-Lenhart syndrome refers to a variant of Graves' disease where there are coexistent autonomous thyroid nodules. It is better described as Graves' disease with coexistent with multinodular goiter or nodular Graves' disease 1, as most authors consider it a distinct sub-entity of Graves’ . 

The syndrome is rare with reported prevalence somewhere between 1-4.1% in patients with Graves´disease 5,7.

Occurrence of the autoimmune disease with stimulatory auto antibodies to TSH receptor in a co-existing nodular gland.

Ultrasound

Depicts both nodules and thyroidtítis. Feature suggesting thyroiditis are

  • diffusely enlarged gland
  • diffusely hypoechoic parenchyma
  • markedly increased vascularity, so called "thyroid inferno"

Albeit the ultrasound appearances are usually indistinguishable from those seen in Hashimoto´s or de Quervain´s thyroidis, the clinical picture (and blood samples) usually makes diagnosis straightforward.

Scintigraphy

can be done with Tc99m pertechnetate or I123 iodine. 

Imaging appearances are those of generally high degree of uptake (as in Graves´ disease) together with one or more nodules lacking significant uptake - cold nodules.

In the course of therapy, along with normalization of TSH levels, these initially cold nodules may alternate their degree of uptake, not infrequently changing to hot nodules 8-9.

Initial therapy usually consists of antithyroid drugs. Once thyroid hormone levels are under control, definite therapy options comprise

  • radionuclide therapy (once malignancy is ruled out) and
  • surgery (which some authors prefer for multiple nodules). 

It was first described in 1911 by the American surgeons David Marine and Carl H. Lenhart (Cleveland, Ohio) on histopathological and iodine content studies of goiter. They encountered eight cases of synchronous goiter and adenoma 4-5.

A list of differential diagnosis for cold nodules comprise both benign and malignant entities, which have been quantified in one larger single-center study 7:

  • great majority comprising benign entities e.g.
    • autoimmune changes
    • coexisting nodular goiter
  • incidence of thyroid malignancy in roughly 10% of all nodules


Scintigraphically cold nodules with ultrasound features suspicious for malignancy are usually biopsied, especially before radio iodine therapy.

 

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Article Information

rID: 10481
System: Head & Neck
Section: Syndromes
Synonyms or Alternate Spellings:
  • Marine-Lenhart syndrome
  • Nodular Graves´ disease
  • Graves´ disease with functioning nodules

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