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51 52 53 4 Dear Editor, 54 Common management options for Graves' disease (GD) include medical treatment, 55 radioactive iodine (RAI) ablation or surgery. Thionamides (carbimazole, methimazole and 56 propylthiouracil) are the first-line medical treatment of GD. Due to potential hepatotoxicity, their 57 use in the setting of underlying hepatic disease can be challenging. For such cases and if 58 thyroidectomy or RAI cannot be rapidly implemented, alternative medical strategies are not 59 well-established.60We report the case of a 28-year-old Caucasian female diagnosed with type I autoimmune 61 hepatitis (AIH) with severely altered liver function tests (alanine aminotransferase of 1437 U/l, 62 total bilirubin of 286 µmol/l).An undetectable TSH prompted a targeted history that revealed 63 recent restlessness, rapid heartbeat and increased stool frequency. Free thyroxine (fT4) and free 64 triiodothyronine (fT3) were more than 2-fold increased. Ultrasonography showed a normally 65 sized but heterogeneous thyroid with increased vascularity. Autoantibodies against the 66 thyrotropin receptor (TRAb) were strongly positive; a diagnosis of GD was made. Due to the 67 AIH, oral prednisone was started at 50 mg/day, with rapid improvement of hepatic function, 68 allowing for progressive tapering after 2 weeks with concomitant introduction of azathioprine. 69Given the severe hepatitis, thionamides were withheld in accordance with ATA guidelines 70 recommending caution in case of more than 5-fold transaminase elevation. Propranolol and low 71 dose cholestyramine were prescribed for 3 weeks. A rapid decrease of both fT4 and fT3 was 72 observed as soon as 48 hours after glucocorticoid (GC) initiation. After 1 month of 73 immunosuppressive treatment, liver function tests, fT4 and fT3 were normal. The TRAb titer 74 progressively decreased, becoming negative at 6 months of treatment (Fig. 1).