SAT-582 Autoimmune Hepatitis Presenting with Graves Disease

Graves disease, the most common cause of hyperthyroidism in the world has an incidence peak between 30 and 50 years of age. It is more frequent in women that in men with a ratio of 5:1. The typical presentation is thyrotoxicosis, goiter and opthalmopathy. The most specific laboratory finding is the activating autoantibodies directed against the thyrotropin receptor, present in up to 98% of untreated patients. Considering the autoimmune nature of the disease, it is not uncommon that patients with the disease present with other autoimmune identities. We present a 22 year old woman diagnosed with Graves disease two years previous, taking methimazole irregularly for 1.5 years. Iodine treatment was given with previous suspension of methimazole a week before. Three days before Iodine she presents jaundice and malaise and comes into the emergency room. Laboratory studies showed transaminases that reached a maximum level of AST 1601U/L (NV: 12-38U/L) ALT 1407U/L (NV: 7-41), total bilirubin of 34.4mg/dl (NV: 0.3-1.3mg/dl) with a conjugated bilirubin of 29.9mg/dl (NV: 0.1-0.4mg/dl) and alkaline phosphatase of 762U/L (NV: 33-96U/L), TSH 0.015 mUI/L T4L 90 pmol/L, abdominal ultrasound showed cholecystitis without cholelithiasis or enlargement of the bile duct and markers of viral hepatitis were negative. A liver biopsy was performed due to hepatocellular injury that reported chronic severe inflammatory infiltrate and acute portal with focal interfase lesion with plasmocytes. Mild fibrous expansion of portal spaces compatible with chronic active hepatitis of probable autoimmune etiology. The autoimmune labs reports showed IgG 2146mg/dl, Antinuclear antibodies negative, Anti smooth muscle antibodies negativa and anti mitochondrial antibodies that were positive. In this case the diagnosis of autoimmune hepatitis and primary biliary cirrhosis was made considering an overlap disease in the context of hyperthyroidism. Patients with Graves disease can have other autoimmune diseases such as autoimmune hepatitis which should be actively searched as a differential diagnosis. Other hepatic diseases such as viral hepatitis, drug induced hepatitis or deposit disease should be ruled out. Smith, T; Hegedüs, L. Review Article: Graves` Disease. N Engl J Med 2016;375:1552-65. Menconi, F; Marcocci, C; Marinò, M. Review: Diagnosis and Classification of Graves` disease. Autoimmun Rev (2014), http://dx.doi.org/10.1016/j.autrev.2014.01.013. Teufel, A; Weinmann, A; Kahaly, G; et all. Concurrent Autoimmune diseases in patients with Autoimmune hepatitis. J Clin Gastroenterol 2010;44:208-213. Wang, R; Tan, J; Zhang, G; et all. Risk factors of hepatic dysfunction in patients with Graves´ hyperthyroidism and the efficacy of 131iodine treatment. Medicine (2017) 96:5. Jhee, J; Kim, H; Kang, W; et all. A case of autoimmune hepatitis combined with graves disease. Korean J Gastroenterol; 2015; 65, 48-51.