Grave’s Disease with Severe Hepatic Dysfunction: A Diagnostic and Therapeutic Challenge

Abstract

Hepatic dysfunction in a patient with thyrotoxicosis may result from hyperthyroidism per se, as a side effect of antithyroid drugs, and causes unrelated to hyperthyroidism which sometimes causes diagnostic and therapeutic difficulties. A young female patient was admitted to our hospital with symptoms of thyrotoxicosis, diffuse goiter and ophthalmopathy along with cholestatic pattern of jaundice, and proximal muscle weakness. She was treated with propylthiouracil with gradual recovery. She was continuing her antithyroid medication with regular follow-up. The patient was readmitted a few months later with worsening thyrotoxicosis, proximal muscle weakness, fever, and a hepatocellular pattern of jaundice with sepsis. Propylthiouracil was stopped and lithium along with steroid coverage was given to control her thyrotoxicosis which was later changed to methimazole. Broad spectrum antibiotic therapy was also started but without any response. During her hospital stay, the patient also developed a flaccid paraplegia resembling Guillain-Barre syndrome. IV steroid was started for the neuropathy but meanwhile the patient succumbed to her illness. So in centers where facility for radioiodine therapy is not readily available, some definite well-tested protocols should be formulated to address such common but complicated clinical situations.

Severe hyperthyroidism without symptoms due to nonthyroidal illness in a child with acute hepatitis: case report and literature review

“…Although there are multiple case reports of cholestasis and severe liver dysfunction presenting in patients with hyperthyroidism, these are mainly adult patients, many of whom have associated comorbid conditions 33–35,46–49 . Additional causes for the liver dysfunction in these patients may include concomitant autoimmune liver disease, drug‐induced dysfunction from antithyroid medication, and/or sepsis 49 . In the pediatric population, there are a few case reports of cholestasis and/or liver failure presenting as neonatal hyperthyroidism due to maternal Graves’ disease 50–56 .…”

Risk factors of hepatic dysfunction in patients with Graves’ hyperthyroidism and the efficacy of 131iodine treatment

“…[ 1 , 2 ] Although most patients have no obvious clinical symptoms, except for abnormal liver function indices, serious liver injury, and even liver failure can occur in a few patients. [ 3 – 5 ]…”

Liver dysfunction associated with hyperthyroidism: Lessons from 2 Case reports

“…It is worth noting that the liver is a major site for the manufacturing of proteins that bind thyroid hormones such as the albumin, transthyretin and thyroxine‐binding globulin 4,15 These hormones, if not in right amounts will fail to serve their normal function of maintaining the serum‐free T4 and T3 concentrations within narrow limits, yet ensure their immediate release and continuous availability to tissues 4,15 . Other mechanisms noted to cause deranged liver enzymes include direct toxic effect of hyperthyroidism 6‐10 . Excess amounts of triiodothyronine induce apoptosis of hepatocytes by the mitochondrial dependent pathway 6‐10 .…”

“…There are six main putative mechanisms contributing to hepatic dysfunction in the context of hyperthyroidism. These include long exposure to excessive thyroid hormone production with effects such as direct liver toxicity from hepatocyte anoxia with free radical damage as a result of the hypermetabolic state, liver glycogen and protein decomposition, and autoimmune‐related liver injury; others include drug‐induced (antithyroid medications) liver injury, the presence of previous underlying liver disease, and hepatic congestion as well as hepatic necrosis from thyrotoxic heart failure 6‐10 :…”