When A Toxic Thyroid Makes The Liver Toxic: A Case Of Thyroid Storm Complicated By Acute Liver Failure

Abstract

Objective: Thyroid storm is a rare life-threatening medical emergency. It is associated with high mortality (10 to 30%). Though there may be mild derangements in liver function tests (LFTs), acute liver failure (ALF) is infrequently reported and its pathophysiology is poorly understood. We hereby report a case of ALF in a patient with thyroid storm. Methods: A 41-year-old female with history of Graves disease (non-compliant with treatment) complicated by multiple episodes of thyroid storm and atrial fibrillation (Afib) presented with exertional dyspnea and productive cough. She was found to be in Afib with rapid ventricular rate and new-onset cardiomyopathy (left ventricular ejection fraction of <20%). She was noted to have a large, nontender thyroid gland with bruit; thyroid function tests were consistent with uncontrolled hyperthyroidism. Results: Two days after initiating treatment with methimazole and propranolol, she became increasingly lethargic, confused, and developed asterixis and icterus. LFTs were consistent with ALF. Methimazole was stopped due to potential hepatotoxicity. Steroids, cholestyramine, and Lugol iodine were started for thyroid storm. Liver ultrasound showed heterogeneous liver texture consistent with acute inflammation. The patient subsequently improved with conservative management and control of thyroid storm. Once clinically stable, she underwent thyroidectomy as a definitive treatment of her Graves disease. Conclusion: The occurrence of ALF in patients with thyroid storm has rarely been reported in the literature and is associated with high mortality. Hyperthyroidism has been hypothesized to injure the liver through several mechanisms which we will discuss in this case report.

Thyroid Dysfunction and Dysmetabolic Syndrome: The Need for Enhanced Thyrovigilance Strategies

“…Patients with acute thyrotoxicosis may show liver dysfunction ranging from mild transaminitis to profound cholestatic liver dysfunction [ 61 , 62 ].…”

“…TH therapy is also an independent predictor of renal outcome in these patients. Medications, such as methimazole and propylthiouracil, used to treat hyperthyroidism, can also alter liver function [ 61 , 75 ]. T4 supplementation has benefits on NAFLD in patients with significant SHypo or SHypo with dyslipidemia [ 76 ].…”

Thyroid Storm Presenting as Acute Liver Failure in a Patient with Graves’ Disease

“…The existing literature on ALF secondary to thyroid storm is limited to a few case reports. Almost 15% to 76% of patients with untreated hyperthyroidism present with mildly elevated LFTs, ALF in this group of patients is extremely uncommon [1,[5][6][7][8][9]. The exact mechanism of ALF in thyroid storm is still controversial.…”

Macular Rash, Thrombocytopenia, and Hyperbilirubinemia in a Preterm Infant

“…Hyperthyroidism is not typically thought to be associated with cholestasis; however, it has been reported in both the pediatric and adult population [8–10]. There are several explanations for liver dysfunction in hyperthyroidism.…”

“…T3 is involved in bilirubin mechanism, and increased levels are thought to cause accumulation of bilirubin precursors. Furthermore, as discussed earlier, hyperthyroidism can lead to increased cardiac output and heart failure which can also contribute to abnormalities in liver function [8].…”