Hepatic Dysfunction with Thyroid Crisis

Abstract

Purpose: Introduction: Acute thyroid crisis can present with significant hepatic dysfunction. The etiology of this dysfunction remains unclear. Case Presentation: A previously healthy 21-year-old man presented with atrial fibrillation with rapid ventricular response. He reported orthopnea and paroxysmal nocturnal dyspnea for two weeks. On exam he was thin, diaphoretic and tachycardic with pitting edema to the mid-thigh bilaterally. Laboratory testing revealed hepatic dysfunction with an alkaline phosphatase of 160(U/L), AST 2,850(U/L), ALT 1,895(U/L), total bilirubin 5.6(mg/dL), direct bilirubin 1.8(mg/dL) and INR 2.7. Albumin was normal. Infectious, toxic and autoimmune causes of acute hepatitis were ruled out. Additional testing included a free thyroxine of 7.7(ng/dL); free T3 17.6(pg/ml) with thyroperoxidase antibodies greater than 950(IU/ml). He was diagnosed with acute hepatitis secondary to Graves' Disease (GD). Discussion: There is little data in the literature regarding hepatic dysfunction and thyrotoxicosis. We performed a retrospective review of adult patients admitted to Mayo Clinic Rochester with acute thyrotoxicosis from 1998-2008. Fourteen patients were identified of which eleven had liver function tests performed during their admission. Of those with liver function tests reported, the average age at admission was 45 (21-81). The etiology was thought to be GD in the majority (91%). Nine of eleven patients (82%) had some degree of hepatic abnormality as defined by elevated liver enzymes or INR, or decreased albumin. Seven had an elevation in transaminases and two had isolated synthetic dysfunction. The mean values of abnormal results were: AST 605(U/L) (69-2850), ALT 649(U/L) (66-1895), Alkaline phosphatase 170(U/L) (129-252), bilirubin total/indirect 2.9/1.3(mg/dL) (1.2/0.6-5.6/2.5). The mean elevated INR was 1.8 (1.4-2.4) and the average albumin was 3.0(g/dL) (2.3-3.4). 54% of the patients required treatment in an intensive care setting. Conclusions: Acute thyroid crisis is a rare condition but can be associated with significant hepatic abnormalities which are highly variable in character and severity. The bulk of these cases appear to be secondary to GD. With appropriate treatment for his hyperthyroidism, our patient's hepatic dysfunction normalized. Thyrotoxicosis should be considered as a reversible etiology in the differential diagnosis for patients who present with otherwise unexplained acute hepatitis.