A Case of Thyroid Crisis With Worsening Jaundice Despite Improvements in Heart Failure

Abstract

We herein present a case of a 33-year-old woman who was referred to our hospital for dyspnea on effort 2 months before her admission. Although diffuse enlargement of the thyroid gland occurred at the age of 23, she did not undergo detailed medical examinations. She was diagnosed with hyperthyroidism due to Graves' disease, and the administration of methimazole was initiated at a dosage of 30 mg/day. She had congestive heart failure, rapid atrial fibrillation, and disseminated intravascular coagulation on admission. Thyroid crisis was diagnosed based on the diagnostic criteria of the Japan Endocrine Society (second edition). Although cardiac function and heart failure symptoms improved, her total bilirubin level continued to increase and peaked at 28.8 mg/dL. Her bilirubin level was reduced by anti-thyroid drugs and eventually normalized in parallel with improvements in thyroid function. Jaundice may have occurred as a secondary consequence of cholestasis due to hyperthyroidism because other causes such as drug-induced or autoimmune liver dysfunction were ruled out. We herein report a rare case of thyroid crisis with worsening jaundice despite improvements in heart failure. This case demonstrated that obtaining a detailed medical history and a careful examination of the clinical course were useful for reaching the differential diagnosis of severe jaundice and achieving steady improvements in this serious medical condition.

Hyperthyroidism and hepatic dysfunction: Report of 17 cases

“…Thyroid hormones are glucuronidated and sulfated within the liver and subsequently excreted into bile, and also maintain the metabolism of bilirubin by regulating glucuronyl transferase and ligandin, a hepatic transport protein. 10 Derangements in LFTs are common even in patients with subclinical hyperthyroidism but synthetic liver dysfunction is rare. 11 A large number of series have reported the prevalence of liver test abnormalities, ranging between 15% and 76% of patients with hyperthyroidism.…”

“…Hepatic dysfunction is commonly observed in patients with thyroid disease. Thyroid hormones are glucuronidated and sulfated within the liver and subsequently excreted into bile, and also maintain the metabolism of bilirubin by regulating glucuronyl transferase and ligandin, a hepatic transport protein . Derangements in LFTs are common even in patients with subclinical hyperthyroidism but synthetic liver dysfunction is rare .…”

“Stormy” jaundice – an unusual presentation of thyrotoxic crisis

“…Jaundice is a potential symptom of heart failure due to passive liver congestion or acute ischemic hepatitis 25 . However, serum bilirubin and aminotranferase levels are usually just slightly elevated, on contrary to values reported in the present case.…”