Perplexing case of liver failure in a patient with hyperthyroidism and chronic hepatitis C

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 449-497-Thyroid Neoplasia & Case Reports
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-479
Mallika Bhat*1, Guy Valiquette2 and Monica G D Schwarcz3
1New York Medical College, Valhalla, NY, 2New York Med College, Valhalla, NY, 3New York Medical College, valhalla, NY
Perplexing case of liver failure in a patient with hyperthyroidism and chronic hepatitis C 

Mallika Bhat, MD, Guy Valiquette, MD, Monica Schwarcz, MD

Westchester Medical Center, Valhalla NY

Background: It is established that hyperthyroidism is associated with liver dysfunction. We present a severe case of liver dysfunction secondary to thyroid storm that warranted consideration for a liver transplant, but which resolved with treatment of the hyperthyroidism. 

Clinical Case: A 56 year old female with history of diabetes, hypertension, chronic hepatitis C, 16 year history of hyperthyroidism due to multinodular goiter and depression was admitted with fatigue, nausea, abdominal pain and jaundice. She was afebrile, hemodynamically stable but tachycardic. She was arousable but agitated with episodes of delirium. She appeared icteric with mild tremors but no asterixis. Lab studies revealed anemia and a normal basic metabolic profile. Liver function tests were: AST: 173 (4-35U/L), ALT: 103 (6-55U/L), alkaline phosphatase: 143 (40-150U/L), total bilirubin: 13.8 (0.2-1.3 mg/dl), direct bilirubin: 10.9 (0.1-0.6 mg/dl). Her thyroid function tests showed hyperthyroidism with TSH: 0.019 (0.350-4.700 mIU/l), Free T4: 5.4 (0.7-1.9 ng/dl), Total T3: 288.1 (79-149 ng/dl).

She was initially treated with methimazole and propranolol. Due to concern of hepatic necrosis methimazole was stopped after 2 days and she was started on lithium. Definitive plan included a possible liver transplant and treatment of hyperthyroidism with I131. Despite therapeutic lithium levels for 10 days, she did not improve and was started on PTU. After an initial response, she became febrile, delirious and was transferred to the intensive care unit. PTU was held due to concern for drug fever. She was listed for liver transplant. The total bilirubin reached a peak value of 40.8 mg/dl with a direct bilirubin of 28.1mg/dl. Due to overall clinical deterioration, I131 therapy was deferred and thyroidectomy was planned. She was restarted on PTU. Her mental status, LFTs and TFTs improved after 1 week. Due to the improvement in her clinical status, she was observed without a transplant. There was further improvement in her mental status, LFT’s and TFT’s. She was discharged on PTU. Her labs 10 weeks later showed:  AST: 102 U/L, ALT: 59 U/L, alkaline phosphatase: 110 U/L, total bilirubin: 2.5 mg/dl, direct bilirubin: 2.2 mg/dl, TSH: 0.023 mIU/l, FreeT4: 2.1 ng/dl, Total T3: 131 ng/dl. LFTs improved in parallel with TFTs without specific treatment of the hepatitis. The final diagnosis was thyroid storm presenting as acute liver failure. She subsequently underwent a thyroidectomy.

Conclusion: Severe hyperthyroidism can present as dramatic worsening of underlying chronic liver disease. It is important to establish the proper diagnosis to treat the patient appropriately.

Nothing to Disclose: MB, GV, MGDS

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