This case report describes a 76-year-old male patient diagnosed with Marine-Lenhart syndrome. The patient had a history of Graves' disease treated with antithyroid drugs. Tests showed suppressed TSH levels and the patient was referred to an endocrinology department. Exams including ultrasound and scintigraphy revealed the patient had Graves' disease along with a hyperactive nodule in the thyroid, consistent with Marine-Lenhart syndrome. The patient was treated with antithyroid drugs followed by radioactive iodine therapy. Follow up showed improvement of hyperthyroidism symptoms. Marine-Lenhart syndrome is a rare cause of hyperthyroidism where a patient has Graves' disease concurrently with a hyperfunctional thyroid nodule.

1. Marine Lenhart syndrome in the 76
year- old patient- case report.
Tomasz Z. Zuzak1, Michał Filip1, Anita Wdowiak1,
Monika Hałgas1, Jan S. Witowski2, Justyna Kocór3
1Students’ Scientific Society at Diagnostic Techniques Laboratory,
Medical University of Lublin, Poland
2Students’ Scientific Society at 2nd Department of General Surgery,
Jagiellonian University, Kraków, Poland
3Student's Scientific Society, Department of Anesthesiology , Intensive
Treatment and Emergency Medicine, Medical University of Silesia,
Katowice, Poland

2. Backgrounds
 Hyperthyroidism:
1. Graves’ disease (60%)
2. Toxic adenoma (=Plummer disease) (30%)
3. Toxic multinodular goiter (=MNG/ Goetsch
disease) (ca 5%)
 Graves' disease is often accompanied by nodular
changes in the thyroid gland (15- 30%):
 Hypoactive nodules (95%)
 Hyperactive nodules (1-3%)
 Other lesions: pseudo-nodules, nodular goiter,
hyperplastic nodules, differentiated thyroid cancer

3. Backgrounds (2)
 In 1911 American surgeons David Marine and Carl
H. Lenhart (Cleveland, Ohio) encountered eight
cases of synchronous goiter and adenoma on
histopathological and iodine content studies of
goiter (Marine D., Lenhart CH.: Patological anatomy of
exophthalmic goiter. Arch Intern Med Chicago 8, 1911)
 The coexistance of Graves’ disease and
hyperactive nodule(AFTN) is known as
Marine- Lenhart syndrome

4. Backgrounds (3)
 Prevalance: 0.8–2.7 % among patients with
Graves’ disease
 The sizes of these AFTN ranged from 2.5 to 50 mm
(N.D. Charkes et al. 1997)
 The therapy of choice is based on the radioiodine
therapy (I-131) – RAI
 Treatment might be more difficult due to the higher
dose of RAI treatment needed compared with
patients having Graves’ disease alone

5. Case report
 76- year old male patient treated with antithyroid agents for 5
months due to Graves’ disease was qualified for PCI due to
prolonged history of stable coronary artery disease
 Preliminary studies shown the reduced levels of TSH
TSH= 0.0041 mU/L; N= 0.27- 5 mU/L (17.01.2017)
 Unstabilized hyperthyroidism was suspected
 The patient was disqualified from Percutaneus Coronary
Intervention (PCI) and directed to Clinical Department of
Endocinology with Laboratory for Nuclear Medicine

6. Case report (2)
 Patient’s retrospective blood tests results:
 17.09.2016
 TSH= 0.0049 mU/L (N=0.27- 5 mU/L)
 fT3= 6.8 pmol/L (N=2.25– 6 pmol/L)
 fT4= 21 pmol/L (N=10- 25 pmol/L)
 13.12.2016
 TSH= 0.0043 mU/L (N=0.27- 5 mU/L)
 fT3=8.9 pmol/L (N=2.25– 6 pmol/L)
 fT4= 35 pmol/L (N=10- 25 pmol/L)
 TRAK ab = 48 U/L GRAVES’ DISEASE

7. Case report (3)
 In Clinical Department of Endocinology with
Laboratory for Nuclear Medicine Graves’ disease
was confirmed by further examinations
 USG Neck examination and scintigraphy with
24-hour iodine uptake were administrated

8. Case report (4)
 USG examination of thyroid gland (17.01.2017):
 The thyroid gland is not enlarged, the shape and
echogenicity- normal, heterogeneous parenchymal structure
with numerous focal lesions of 2-5 mm diameter were found.
Cystic degeneration and two normo-genic nodules 5 mm in
the left lobe. Dimensions - right lobe 18x17x56 mm; left lobe
18x16x53mm. Neck free from nodal changes.
 Due to founded lesions, patient was directed to Laborartory
for Nuclear Medicine to perform thyroid scintigraphy and
thyroid 24-hour iodine uptake

9. USG examination- left lobe

10. USG examination (2)- right lobe

11. Case report (5)
 Scintigraphy & thyroid 24-hour iodine uptake
examination (18.01.2017):
 In the scintigraphic examination, a bipolar thyroid gland was
labeled, which is typically located, not enlarged, with the
lower right lobe ranging slightly below the yoke of the
sternum. Radiomarkers accumulate in the form of a hot tumor
in the lower pole of the right lobe. The remaining thyroid
parenchyme catches the radioisotope traces.
 Conclusion: The scintigraphic image may correspond to
an incompletely compensated autopsy in the right lobe.
 Due to founded lesions and retrospective history of
Graves’ disease patient was diagnosed with
Marine- Lenhart syndrome

12. Scintigraphy & thyroid
24-hour iodine uptake

13. Case report (6)
 Patient was qualified for the treatment:
1. Thiamazol (Metizol®) dose: 15mg/ day –
for two weeks before causative treatment
2. Radioiodine therapy (16.02.2017)
 Administration an individualy calculated
dose of radioiodine (I-131) = 5.5 mCi
 The patient was released home with recommended
admission of: Encorton®, Kalipoz®, Polprazol®,
Vitrum Calcium®

14. Case report (7)
 First check- up visit in Nuclear Medicine Doctor
Clinic (23.03.2017):
 Blood test results:
o TSH= 0.018 mU/L (N=0.27- 5 mU/L)
o fT3= 2.74 pmol/L (N=2.25– 6 pmol/L)
o fT4= 13.45 pmol/L (N=10- 25 pmol/L)
 Next check- up visit: 3 months after RAI therapy-
May 2017
 Clinical and laboratory markers of hyperthyroidism
subsided and patient was directed to Cardiology
Department for PCI qualification

15. Conclusions
1. Marine- Lenhart syndrome is the rare cause of
hyperthyroidism.
2. It afects only 0.8- 2.7% patients diagnosed with
Graves’ disease.
3. Therapy of choice is based on radioiodine therapy
(I-131).
4. RAI is known as far safer therapy.
5. Thyroid gland surgery is recognized as the
second choice therapy.
6. Hyperthyroidism can affect and complicate many
other diseases e.g. coronary artery disease.

16.  Case and images courtesy of Clinical
Department of Internal Medicine, Nephrology,
Endocrinology with Laboratory for Nuclear
Medicine; Clinical Voivodeship Hospital nr 2 in
the Name of The Saint Queen Jadwiga in
Rzeszów, Poland

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18. Thank You for Your attention!