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 multinodular goitre or nodular Graves disease 1

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

Occurrence of Graves disease, with stimulatory autoantibodies to thyroid-stimulating hormone (TSH) receptor, with coexisting nodularity of the thyroid gland.

Depicts both nodules and thyroiditis. Features suggesting thyroiditis are:

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

The ultrasound appearances are usually indistinguishable from Hashimoto or de Quervain thyroiditis, however the clinical picture and blood samples usually make diagnosis straightforward.

Can be done with 99mTc-pertechnetate or 123I-iodine

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

In the course of therapy, along with normalisation 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 in Cleveland, Ohio, on histopathological and iodine content studies of goitre. They encountered eight cases of synchronous goitre and adenoma 4,5.

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

  • great majority comprising benign entities such as:
    • autoimmune changes
    • coexisting nodular goitre
  • incidence of thyroid malignancy in ~10% of all nodules

Scintigraphically-cold nodules with sonographic features suspicious for malignancy are usually biopsied, especially before radioiodine therapy.

Share article

Article information

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

Support Radiopaedia and see fewer ads

Cases and figures

  • Drag
    Case 1
    Drag here to reorder.
  • Updating… Please wait.
    Loadinganimation

    Alert accept

    Error Unable to process the form. Check for errors and try again.

    Alert accept Thank you for updating your details.