Autoimmune Hepatitis Refractory to Treatment Due to Underlying Grave's Disease.

Rahul Sawhney,Sadhna Dhingra,Gagan K Sood

doi:10.7759/cureus.4598

Rahul Sawhney, Sadhna Dhingra + Show 1 more

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https://doi.org/10.7759/cureus.4598

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Abstract

A 24-year-old Hispanic woman presented to our facility with a two-week history of abdominal pain, nausea, vomiting, diarrhea, jaundice, and scleral icterus. Initial laboratory workup revealed elevated transaminases, direct hyperbilirubinemia, and positive anti-smooth muscle antibody. Liver biopsy confirmed the diagnosis of autoimmune hepatitis and our patient was started on oral prednisone therapy. Her liver enzymes initially began to normalize but then spontaneously started up-trending. She was subsequently readmitted to the hospital for further management, at which time she also complained of palpitations, heat intolerance, and sweating. Laboratory workup revealed hyperthyroidism secondary to Grave’s disease. Our patient was not a candidate for methimazole or propylthiouracil treatment due to her hepatic dysfunction, so she was started on hydrocortisone due to its secondary effect of decreased conversion of thyroxine to triiodothyronine. She achieved biochemical remission of her autoimmune hepatitis on this regimen and was transitioned back to oral prednisone therapy. Her liver enzymes normalized once she underwent radioactive iodine ablation of her thyroid. This clinical course suggests that autoimmune hepatitis with concurrent Grave’s disease may be refractory to treatment until the underlying hyperthyroid state is corrected.

Highlights

Autoimmune hepatitis (AIH) is a chronic inflammatory condition characterized by hepatocellular inflammation secondary to autoantibody-induced lymphocytic proliferation [1]
We present a case of AIH with associated Grave’s disease in which the underlying hyperthyroidism seemingly contributed to progressive liver dysfunction
A 24-year-old Hispanic woman with a past medical history of post-partum pre-eclampsia presented to the emergency department with a two-week history of abdominal pain, nausea, vomiting, diarrhea, jaundice, and scleral icterus

Summary

Introduction

Autoimmune hepatitis (AIH) is a chronic inflammatory condition characterized by hepatocellular inflammation secondary to autoantibody-induced lymphocytic proliferation [1]. Aside from obesity, she denied other risk factors for liver disease. ALT: alanine aminotransferase; AST: aspartate aminotransferase; T4: thyroxine Given her hepatic function, the patient was not a candidate for standard therapy with methimazole or propylthiouracil. The patient was not a candidate for standard therapy with methimazole or propylthiouracil She was instead started on high-dose hydrocortisone, which provided an added benefit of decreased peripheral conversion of T4 to T3 [6]. Her hyperthyroid symptoms improved while AST, ALT, and total bilirubin decreased by nearly 75% within one week. The patient remained stable on standard immunosuppressive therapy, with 20 mg prednisone and 150 mg azathioprine daily

Discussion

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Disclosures