SUN-508 Dissociation of Clinical Course of Coexisting Autoimmune Hepatitis and Graves Disease

Abstract

Title: Dissociation of Clinical Course of Coexisting Autoimmune Hepatitis and Graves Disease Introduction: The association between Graves’ disease and coexisting autoimmune hepatitis is well known. Treatment of autoimmune hepatitis with glucocorticoids can concurrently lower thyroid hormone levels. Additionally, recurrence of hyperthyroidism has been shown to be associated with recurrence of autoimmune hepatitis. We present a case of a patient with autoimmune hepatitis and Graves’ thyrotoxicosis, which initially improved with prednisone therapy, but thyrotoxicosis recurred during the prednisone taper while hepatitis stayed in remission. Clinical Case: A 47-year old female initially presented with fatigue, nausea, and jaundice. Liver enzymes showed elevated AST (1634 U/L) and ALT (1956 U/L) with total bilirubin 15.1 mg/dL. Liver biopsy was consistent with autoimmune hepatitis. Treatment was initiated with ursodiol 300 mg TID and liver enzymes improved to ALT 579 IU/L and AST 544 IU/L with total bilirubin 1.9 mg/dL. Nine months later, she presented with worsening upper and lower extremity weakness, slurred speech, abdominal pain, and nausea and vomiting. AST and ALT were again elevated to >1,000 U/L. TFTs were checked due to symptoms of palpitations and heat intolerance. TSH was 0.024 uIU/mL with elevated free T4 of 3.74 ng/dL and TSI of 435%. She was treated with prednisone, cholestyramine, and propranolol and discharged with a one-month prednisone taper starting at 60 mg daily. LFTs and TFTs normalized after one month. Cholestyramine was discontinued and prednisone was tapered to 5 mg daily. Seven months later, she had symptoms of palpitations and heat intolerance. TFTs were consistent with hyperthyroidism (TSH 0.049 uIU/mL, free T4 3.96 ng/dL). LFTs remained in normal range. Since thionamides have relative contraindications in patients with liver disease, prednisone was increased from 5 mg to 20 mg daily and cholestyramine was resumed to treat hyperthyroidism. After five months, TSH remained suppressed to 0.019 uIU/mL however free T4 improved to 1.74 ng/dL. The patient was referred for total thyroidectomy. Conclusion: This case illustrates an example of the rarely reported occurrence of thyrotoxicosis recrudescence despite initial improvement with treatment of underlying autoimmune hepatitis. Recognition of recurrence of hyperthyroidism independent of recurrence of autoimmune hepatitis indicates the need for early definitive therapy for hyperthyroidism.