November 1, 2014

Thyroid inferno

By Daniel Cabrera

Authors: Venkatesh Bellamkonda, M.D. (@VenkBellamkonda) and Tobias Kummer, M.D. (@buskloper)

thyroid inferno header


I find myself on shift occasionally caring for people who are confused, tachycardic and hypertensive.  Sure, most of the time, this is because they made a stop at my friendly neighborhood drug dealer, but sometimes the cause is hyperthyroidism.  Certainly, the treatment is similar…at least initially.  To make the diagnosis, you can check a TSH and free T4 and wait for them to return.

If you want though…you can use ultrasound for that…No, really, you can!



Use a high frequency transducer positioned with the probe marker aimed at the patient’s right side and slowly sweep through the right and left lobes of the thyroid as well as the isthmus.

When you feel confident that you have seen the whole thyroid gland (make notes of cysts, atrophy, etc.), apply the color Doppler box over the glandular parenchyma, If you see a lot of colors (A.K.A. the “inferno”), the patient is highly likely to have hyperthyroidism.  Lack of color does not exclude the diagnosis but certainly reduces the likelihood of disease.


Here is a video clip of what a normal thyroid gland looks like with color Doppler applied:


Take a look at the following example of a woman with hyperthyroidism:


Hopefully, you will consider taking a peek with ultrasound the next time you consider hyperthyroidism in your patient.  Cheers!



  1. Ralls, P. W., Mayekawa, D. S., Lee, K. P., Colletti, P. M., Radin, D. R., Boswell, W. D., & Halls, J. M. (1988). Color-flow Doppler sonography in Graves disease:“ thyroid inferno.” American Journal of Roentgenology, 150(4), 781–784.
  2. Williams, E., Chillag, S., & Rizvi, A. (2014). Thyroid Bruit and the Underlying “Inferno.” The American Journal of Medicine, 127(6), 489–490. doi:10.1016/j.amjmed.2013.08.034


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Cool article. I get my thyroid ultrasounded frequently and now it makes a little sense.


Cool article. I get my thyroid ultrasounded frequently and now it makes a little sense.

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