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SUN-578 Severe Hyperbilirubinemia Due to Graves' Thyrotoxicosis

Introduction: Graves’ disease is the most common cause of hyperthyroidism in the United States. Though hepatic dysfunction has been described in patients with thyrotoxicosis due to Graves’ disease, it is an extremely rare cause of severe hyperbilirubinemia. There is limited evidence to guide physici...

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Autores principales: Thampi, Rahul, Shawa, Hassan
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Endocrine Society 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6553239/
http://dx.doi.org/10.1210/js.2019-SUN-578
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author Thampi, Rahul
Shawa, Hassan
author_facet Thampi, Rahul
Shawa, Hassan
author_sort Thampi, Rahul
collection PubMed
description Introduction: Graves’ disease is the most common cause of hyperthyroidism in the United States. Though hepatic dysfunction has been described in patients with thyrotoxicosis due to Graves’ disease, it is an extremely rare cause of severe hyperbilirubinemia. There is limited evidence to guide physicians in the management of hyperthyroidism associated with liver dysfunction, making it a diagnostic and therapeutic challenge. Case Report: 30-year-old woman with no significant history presented with complaints of diarrhea and yellowish discoloration of skin for more than a month. She had generalized itching, hand tremors and a 30 lb. weight loss during this period. On physical examination, she was noted to have tachycardia, scleral icterus, a diffuse non-nodular non-tender goiter, bilateral fine tremors and hyperreflexia. Abdomen was soft and non-tender with no hepatosplenomegaly. Laboratory evaluation showed normal compete blood count, total bilirubin 26 mg/dL, direct bilirubin 17.7 mg/dL, indirect bilirubin 9.1 mg/dL, ALT 49 IU/L, AST 26 IU/L, ALP 265 IU/L. She had biochemical hyperthyroidism with TSH less than 0.01 UIU/ml (0.45-4.5), free T4 of 4 ng/dL (0.6-1.3), total T3 371 ng/dL (79-149). TSI was elevated 2.13 (0-0.55). Further work up of hyperbilirubinemia including hepatitis viral panel, anti-nuclear antibody, anti-mitochondrial and anti-smooth muscle antibodies were negative. Ultrasound of the liver showed no abnormalities. Liver biopsy revealed benign liver with bland canalicular stenosis in central zones. There were no features of autoimmune hepatitis or chronic hepatitis. She underwent I131 ablation with normalization of ALP and bilirubin levels at 3 months follow-up. Discussion: Hepatic dysfunction has been described in patients with hyperthyroidism since it was reported in 1874. It may occur because of hyperthyroidism per se, drug treatment of hyperthyroidism and conditions associated with autoimmune thyroid disease like autoimmune hepatitis and primary biliary cirrhosis. The causes could also be unrelated to hyperthyroidism like viral hepatitis, alcohol abuse, sepsis, cholangitis, medications. Several theories have been hypothesized, but the mechanism of the hepatic dysfunction due to hyperthyroidism per se is not clear. A thorough work up is essential to rule out other potential etiologies. If clinically feasible, liver biopsy may be deferred initially. However, it should be considered if liver function fails to improve despite normalization of thyroid hormone levels. I131 ablation is a safe and effective method of treatment in these patients.
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spelling pubmed-65532392019-06-13 SUN-578 Severe Hyperbilirubinemia Due to Graves' Thyrotoxicosis Thampi, Rahul Shawa, Hassan J Endocr Soc Thyroid Introduction: Graves’ disease is the most common cause of hyperthyroidism in the United States. Though hepatic dysfunction has been described in patients with thyrotoxicosis due to Graves’ disease, it is an extremely rare cause of severe hyperbilirubinemia. There is limited evidence to guide physicians in the management of hyperthyroidism associated with liver dysfunction, making it a diagnostic and therapeutic challenge. Case Report: 30-year-old woman with no significant history presented with complaints of diarrhea and yellowish discoloration of skin for more than a month. She had generalized itching, hand tremors and a 30 lb. weight loss during this period. On physical examination, she was noted to have tachycardia, scleral icterus, a diffuse non-nodular non-tender goiter, bilateral fine tremors and hyperreflexia. Abdomen was soft and non-tender with no hepatosplenomegaly. Laboratory evaluation showed normal compete blood count, total bilirubin 26 mg/dL, direct bilirubin 17.7 mg/dL, indirect bilirubin 9.1 mg/dL, ALT 49 IU/L, AST 26 IU/L, ALP 265 IU/L. She had biochemical hyperthyroidism with TSH less than 0.01 UIU/ml (0.45-4.5), free T4 of 4 ng/dL (0.6-1.3), total T3 371 ng/dL (79-149). TSI was elevated 2.13 (0-0.55). Further work up of hyperbilirubinemia including hepatitis viral panel, anti-nuclear antibody, anti-mitochondrial and anti-smooth muscle antibodies were negative. Ultrasound of the liver showed no abnormalities. Liver biopsy revealed benign liver with bland canalicular stenosis in central zones. There were no features of autoimmune hepatitis or chronic hepatitis. She underwent I131 ablation with normalization of ALP and bilirubin levels at 3 months follow-up. Discussion: Hepatic dysfunction has been described in patients with hyperthyroidism since it was reported in 1874. It may occur because of hyperthyroidism per se, drug treatment of hyperthyroidism and conditions associated with autoimmune thyroid disease like autoimmune hepatitis and primary biliary cirrhosis. The causes could also be unrelated to hyperthyroidism like viral hepatitis, alcohol abuse, sepsis, cholangitis, medications. Several theories have been hypothesized, but the mechanism of the hepatic dysfunction due to hyperthyroidism per se is not clear. A thorough work up is essential to rule out other potential etiologies. If clinically feasible, liver biopsy may be deferred initially. However, it should be considered if liver function fails to improve despite normalization of thyroid hormone levels. I131 ablation is a safe and effective method of treatment in these patients. Endocrine Society 2019-04-30 /pmc/articles/PMC6553239/ http://dx.doi.org/10.1210/js.2019-SUN-578 Text en Copyright © 2019 Endocrine Society https://creativecommons.org/licenses/by-nc-nd/4.0/ This article has been published under the terms of the Creative Commons Attribution Non-Commercial, No-Derivatives License (CC BY-NC-ND; https://creativecommons.org/licenses/by-nc-nd/4.0/).
spellingShingle Thyroid
Thampi, Rahul
Shawa, Hassan
SUN-578 Severe Hyperbilirubinemia Due to Graves' Thyrotoxicosis
title SUN-578 Severe Hyperbilirubinemia Due to Graves' Thyrotoxicosis
title_full SUN-578 Severe Hyperbilirubinemia Due to Graves' Thyrotoxicosis
title_fullStr SUN-578 Severe Hyperbilirubinemia Due to Graves' Thyrotoxicosis
title_full_unstemmed SUN-578 Severe Hyperbilirubinemia Due to Graves' Thyrotoxicosis
title_short SUN-578 Severe Hyperbilirubinemia Due to Graves' Thyrotoxicosis
title_sort sun-578 severe hyperbilirubinemia due to graves' thyrotoxicosis
topic Thyroid
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6553239/
http://dx.doi.org/10.1210/js.2019-SUN-578
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