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Yu H, Zhang W, Shen C, Zhang H, Zhang H, Zhang Y, Zou D, Gong X. Liver dysfunction induced by Levothyroxine Sodium Tablets (Euthyrox®) in a hypothyroid patient with Hashimoto's thyroiditis: case report and literature review. Endocr J 2019; 66:769-775. [PMID: 31217393 DOI: 10.1507/endocrj.ej19-0078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 49-year-old woman with hypothyroidism developed liver dysfunction after increasing dose of levothyroxine (L-T4) (Euthyrox®) from 25 μg to 50 μg. Viral hepatitis, autoimmune hepatitis and non-alcoholic steatohepatitis (NASH) were ruled out with examinations. She had no concurrent medication and had no history of infectious, chronic or any other autoimmune diseases. After cessation of Levothyroxine Sodium Tablets (Euthyrox®), liver enzymes gradually returned to normal. She was diagnosed levothyroxine-induced liver injury, based on criteria proposed in "Diagnosis and treatment guideline on drug-induced liver injury" issued by the Chinese Medical Association (2015). As an alternative 25 μg qod of Levothyroxine Sodium Tablets (Letrox®) was tried and increased gradually up to 75 μg daily. Since then liver enzymes have remained within normal range. The main difference of additive for both tablets is whether it contains lactose or not: Euthyrox® contains lactose which caused no liver injury, thus excluding the possibility that an additive of Euthyrox® contributed to liver injury. The relatively quicker and larger replacement with synthetic T4 for hypothyroidism inducing transient thyrotoxicosis was suspected, although thyroid function was normal. Immune-mediated drug-induced liver injury (DILI) was also not excluded. This is a rare case of drug-induced liver injury due to levothyroxine tablets. It reminded us that when replacement with synthetic T4 for hypothyroidism is done, smaller-dose initiation and slower-speed increase may be useful for treatment of cases similar to genetically susceptible individuals.
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Affiliation(s)
- Hengcai Yu
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - Wen Zhang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
| | - Chengwu Shen
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
| | - Haiqing Zhang
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
| | - Haochao Zhang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - Yahui Zhang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
| | - Dongna Zou
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
| | - Xianwei Gong
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
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Sano M, Homma T, Ishige T, Sawada N, Ihara S, Kinoshita K, Masuda S, Hao H. An autopsy case of hyperthyroid cardiomyopathy manifesting lethal congestive heart failure. Pathol Int 2016; 67:110-112. [PMID: 28008703 DOI: 10.1111/pin.12491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 11/14/2016] [Accepted: 11/25/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Makoto Sano
- Department of Pathology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Taku Homma
- Department of Pathology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Toshiyuki Ishige
- Department of Pathology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Nami Sawada
- Department of Acute Medicine, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Shingo Ihara
- Department of Acute Medicine, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Kosaku Kinoshita
- Department of Acute Medicine, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Shinobu Masuda
- Department of Pathology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Hiroyuki Hao
- Department of Pathology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
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Sousa Domínguez A. Severe acute liver failure and thyrotoxicosis: an unusual association. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2015; 107. [PMID: 26176693 DOI: 10.17235/reed.2015.3607/2014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Thyrotoxicosis is defined as the clinical syndrome resulting from the excess of thyroid hormones in the organism. It has several causes and a wide range of clinical manifestations, from mild tachycardia up to multiple organ failure. Although it is not unusual that patients with thyroid dysfunction have abnormal liver-function test these are usually mild and the initial presentation as severe liver failure is exceptional. We present a case report of a patient who developed a severe acute liver failure due to a non-controlled hyperthyroidsm. Also we conducted a review of all similar cases reported to date in the literature.
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Tokushima Y, Sakanishi Y, Nagae K, Tokushima M, Tago M, Tomonaga M, Yoshioka T, Hyakutake M, Sugioka T, Yamashita SI. Thyroid storm complicated by bicytopenia and disseminated intravascular coagulation. AMERICAN JOURNAL OF CASE REPORTS 2014; 15:312-6. [PMID: 25072662 PMCID: PMC4121396 DOI: 10.12659/ajcr.890519] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PATIENT Male, 23. FINAL DIAGNOSIS Thyroid storm. SYMPTOMS Delirium • diarrhea • fever • hypertension • hyperventilation • tachycardia • weight loss. MEDICATION -. CLINICAL PROCEDURE -. SPECIALTY Endocrinology and Metabolic. OBJECTIVE Unusual clinical course. BACKGROUND The clinical presentation of thyroid storm includes fever, tachycardia, hypertension, and neurological abnormalities. It is a serious condition with a high mortality rate. Furthermore, some other complications affect the clinical course of thyroid storm. Although it is reported that prognosis is poor when thyroid storm is complicated by disseminated intravascular coagulation syndrome (DIC) and leukopenia, reports of such cases are rare. CASE REPORT A 23-year-old man presented with delirium, high pyrexia, diarrhea, and weight loss of 18 kg over 2 months. According to the criteria of Burch and Wartofsky, he was diagnosed with thyroid storm on the basis of his symptom-complex and laboratory data that confirmed the presence of hyperthyroidism. Investigations also found leukopenia, thrombocytopenia, and disseminated intravascular coagulation, all of which are very rare complications of thyroid storm. We successfully treated him with combined therapy including anti-thyroid medication, despite leukopenia. CONCLUSIONS Early diagnosis and treatment are essential in ensuring a good outcome for patients with this rare combination of medical problems.
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Affiliation(s)
| | - Yuta Sakanishi
- Community Medical Support Institute, Faculty of Medicine, Saga University Hospital, Saga city, Japan
| | - Kou Nagae
- Department of General Medicine, Saga University Hospital, Saga city, Japan
| | - Midori Tokushima
- Department of General Medicine, Saga University Hospital, Saga city, Japan
| | - Masaki Tago
- Department of General Medicine, Saga University Hospital, Saga city, Japan
| | - Motosuke Tomonaga
- Department of General Medicine, Saga University Hospital, Saga city, Japan
| | - Tsuneaki Yoshioka
- Department of General Medicine, Saga University Hospital,, Saga city, Japan
| | - Masaki Hyakutake
- Department of General Medicine, Saga University Hospital, Saga city, Japan
| | - Takashi Sugioka
- Community Medical Support Institute, Faculty of Medicine, Saga University Hospital, Saga city, Japan
| | - Shu-ichi Yamashita
- Department of General Medicine, Saga University Hospital, Saga city, Japan
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Hambleton C, Buell J, Saggi B, Balart L, Shores NJ, Kandil E. Thyroid Storm Complicated by Fulminant Hepatic Failure: Case Report and Literature Review. Ann Otol Rhinol Laryngol 2013; 122:679-82. [DOI: 10.1177/000348941312201103] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Thyroid storm is a presentation of severe thyrotoxicosis that has a mortality rate of up to 20% to 30%. Fulminant hepatic failure (FHF) entails encephalopathy with severe coagulopathy in the setting of liver disease. It carries a high mortality rate, with an approximately 60% rate of overall survival for patients who undergo orthotopic liver transplantation (OLT). Fulminant hepatic failure is a rare but serious complication of thyroid storm. There have been only 6 previously reported cases of FHF with thyroid storm. Methods: We present a patient from our institution with thyroid storm and FHF. A literature review was performed to analyze the outcomes of the 6 additional cases of concomitant thyroid storm and FHF. Results: Our patient underwent thyroidectomy followed by OLT. Her serum levels of thyroid-stimulating hormone, triiodothyronine, thyroxine, and transaminase normalized, and she was ready for discharge within 10 days of surgery. She has survived without complication. There is a 40% mortality rate for the reported patients treated medically with these conditions. Of the 7 total cases of reported FHF and thyroid storm, 2 patients died. Only 2 of the 7 patients underwent thyroidectomy and OLT — Both at our institution. Both patients survived without complications. Conclusions: Thyroid storm and FHF each independently carry high mortality rates, and managing patients with both conditions simultaneously is an extraordinary challenge. These cases should compel clinicians to investigate liver function in hyperthyroid patients and to be wary of its rapid decline in patients who present in thyroid storm with symptoms of liver dysfunction. Patients with rapidly progressing thyroid storm and FHF should be considered for total thyroidectomy and OLT.
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Cascino MD, McNabb B, Gardner DG, Woeber KA, Fox AN, Wang B, Fix OK. Acute liver failure with thyrotoxicosis treated with liver transplantation. Endocr Pract 2013; 19:e57-60. [PMID: 23337142 DOI: 10.4158/ep12219.cr] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We describe a young woman with previously undiagnosed thyrotoxicosis who presented with acute liver failure (ALF). METHODS We present a case report and review the relevant literature. RESULTS An extensive evaluation excluded possible causes of ALF other than thyrotoxicosis. The management of thyrotoxicosis posed several unique challenges in the setting of ALF, particularly because we did not want to use potentially hepatotoxic thionamides. The patient was treated with prednisone and propranolol and was started on potassium iodide when she was listed for liver transplantation. She underwent an uncomplicated liver transplant and subsequent thyroidectomy and is doing well. CONCLUSION This well-characterized case describes thyrotoxicosis as a possible cause of ALF after thoroughly excluding other possible causes and illustrates the challenges of simultaneously managing both disorders. To our knowledge, this is the first report of ALF possibly resulting from untreated thyrotoxicosis that was successfully treated with liver transplantation.
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Affiliation(s)
- Matthew D Cascino
- Department of Medicine, University of California, San Francisco, California, USA
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Harada Y, Akiyama H, Yoshimoto T, Urao Y, Ryuzaki M, Handa M. Thyroid storm with multiple organ failure, disseminated intravascular coagulation, and stroke with a normal serum FT3 level. Intern Med 2012; 51:2379-83. [PMID: 22975553 DOI: 10.2169/internalmedicine.51.7974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Thyroid storm is a rare disorder with a sudden onset, rapid progression and high mortality. We experienced a case of thyroid storm which had a devastating course, including multiple organ failure (MOF), severe hypoglycemia, disseminated intravascular coagulation (DIC), and stroke. It was difficult to make a diagnosis of thyroid storm in the present patient, because she did not have a history of thyroid disease and her serum FT3 level was normal. Clinicians should be aware that thyroid storm can occur even when there is an almost normal level of thyroid hormones, and that intensive anticoagulation is required for patients with atrial fibrillation to prevent stroke after thyroid storm.
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Affiliation(s)
- Yuko Harada
- Department of Cardiology, Kawasaki Municipal Ida Hospital, Japan.
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Kandil E, Khalek MA, Thethi T, Abd Elmageed Z, Khan A, Jaffe BM. Thyroid storm in a patient with fulminant hepatic failure. Laryngoscope 2011; 121:164-6. [PMID: 21120833 DOI: 10.1002/lary.21183] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This manuscript describes a 28-year-old patient with a history of Graves' disease who was transferred to Tulane University Hospital with fulminant hepatic failure. He reported associated nausea, vomiting, anorexia, as well as jaundice and abdominal discomfort for a period of 3 weeks prior to his admission. His thyroid function tests on admission were TSH, 0.013 μU/mL; T3, 94.9 μU/mL; T4, 9.37 μU/mL; Free T4, >6 μU/mL. His liver function tests were characteristic of hepatic failure. The patient underwent an emergent liver transplant. His surgery was complicated by heart failure and acute respiratory distress syndrome. Given the patients clinical presentation and laboratory results, a diagnosis of thyroid storm was made and a decision was made to proceed with an emergent thyroidectomy. The posttransplant multiorgan dysfunction was rapidly reversed by prompt thyroidectomy and decisive management. The patient was discharged from the hospital with normal thyroid and liver function tests.
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Affiliation(s)
- Emad Kandil
- Department of Surgery, Section of Endocrinology, Tulane University School of Medicine, New Orleans, Louisiana, USA.
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