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.
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.
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.
Treatment and prognosis
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).
History and etymology
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.
- 1. Intenzo CM, Depapp AE, Jabbour S et-al. Scintigraphic manifestations of thyrotoxicosis. Radiographics. 2003;23 (4): 857-69. Radiographics (full text) - doi:10.1148/rg.234025716 - Pubmed citation
- 2. Chandramouly B, Mann D, Cunningham RP et-al. Marine-Lenhart syndrome. Graves' disease with poorly functioning nodules. Clin Nucl Med. 1992;17 (11): 905-6. Pubmed citation
- 3. Biersack HJ, Biermann K. The Marine-Lenhart syndrome revisited. Wien. Klin. Wochenschr. 2011;123 (15-16): 459-62. Wien. Klin. Wochenschr. (abstract) - doi:10.1007/s00508-011-0029-5 - Pubmed citation
- 4. Marine D, Lenhart CH. Pathological anatomy of exophthalmic goiter. Arch Intern Med. 1911;8:265–316. http://archinte.jamanetwork.com/article.aspx?articleid=653460
- 5. Charkes ND. Graves' disease with functioning nodules (Marine-Lenhart syndrome). J. Nucl. Med. 1973;13 (12): 885-92. Pubmed citation
- 6. EFSUMB Course Book on Ultrasound. EFSUMB. ISBN:0957158106. Read it at Google Books - Find it at Amazon pp.537-41
- 7. Carnell NE, Valente WA. Thyroid nodules in Graves' disease: classification, characterization, and response to treatment. Thyroid. 1998;8 (8): 647-52. Pubmed citation
- 8. Waldherr C, Otte A, Haldemann A et-al. Marine-Lenhart syndrome: a case observation upon 18 years. Nuklearmedizin. 2000;38 (8): 345-8. Pubmed citation
- 9. Nygaard B, Faber J, Veje A et-al. Transition of nodular toxic goiter to autoimmune hyperthyroidism triggered by 131I therapy. Thyroid. 1999;9 (5): 477-81. Pubmed citation