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Elhaj MF, Magboul H, Ahmed AO, Sasi S, Saleh AO. Thyrotoxicosis Presenting With Acute Cholecystitis: A Case Report and Literature Review. Cureus 2021; 13:e20840. [PMID: 35141089 PMCID: PMC8800661 DOI: 10.7759/cureus.20840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2021] [Indexed: 11/05/2022] Open
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Komiya I, Tomoyose T, Yagi N, Ouchi G, Wakugami T. A case of thyrotoxicosis-induced anemia in a patient with painless thyroiditis. Thyroid Res 2021; 14:9. [PMID: 33892761 PMCID: PMC8062610 DOI: 10.1186/s13044-021-00100-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/11/2021] [Indexed: 11/14/2022] Open
Abstract
Background There have been several reports of secondary anemia associated with Graves’ disease. There are no reports of secondary anemia resulting from thyrotoxicosis due to painless thyroiditis (silent thyroiditis). We report the case of a patient with pancreatic diabetes who developed anemia caused by thyrotoxicosis due to painless thyroiditis. Case presentation The patient was a 37-year-old man who visited the hospital complaining of fatigue, palpitations, and dyspnea. His hemoglobin was 110 g/l (reference range, 135–176), and mean corpuscular volume was 81.5 fl (81.7–101.6). His free thyroxine (FT4) was high, at 100.4 pmol/l (11.6–21.9); the free triiodothyronine (FT3) was high, at 27.49 pmol/l (3.53–6.14); TSH was low, at < 0.01 mIU/l (0.50–5.00); and TSH receptor antibody was negative. Soluble IL-2 receptor (sIL-2R) was high, at 1340 U/ml (122–496); C-reactive protein (CRP) was high, at 6900 μg/l (< 3000); and reticulocytes was high, at 108 109 /l (30–100). Serum iron (Fe) was 9.5 (9.1–35.5), ferritin was 389 μg/l (13–401), haptoglobin was 0.66 g/l (0.19–1.70. Propranolol was prescribed and followed up. Anemia completely disappeared by 12 weeks after disease onset. Thyroid hormones and sIL-2R had normalized by 16 weeks after onset. He developed mild hypothyroidism and was treated with L-thyroxine at 24 weeks. Conclusions This is the first case report of transient secondary anemia associated with thyrotoxicosis due to painless thyroiditis. The change in sIL-2R was also observed during the clinical course of thyrotoxicosis and anemia, suggesting the immune processes in thyroid gland and bone marrow.
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Affiliation(s)
- Ichiro Komiya
- Department of Internal Medicine, Okinawa Medical Hospital, 2310 Tsuhako-Nishihara, Sashiki, Nanjo, Okinawa, 9011414, Japan. .,Yagi Internal Medicine Clinic, 4-13-9 Kohagura, Naha, Okinawa, 9000029, Japan.
| | - Takeaki Tomoyose
- Department of Hematology, Okinawa Red Cross Hospital, 1-3-1 Yogi, Naha, Okinawa, 9028588, Japan
| | - Noriharu Yagi
- Yagi Internal Medicine Clinic, 4-13-9 Kohagura, Naha, Okinawa, 9000029, Japan
| | - Gen Ouchi
- Department of Emergency and Critical Care Medicine, University of Ryukyus Hospital, 207 Uehara, Nishihara, Okinawa, 9030215, Japan
| | - Tamio Wakugami
- Department of Internal Medicine, Okinawa Medical Hospital, 2310 Tsuhako-Nishihara, Sashiki, Nanjo, Okinawa, 9011414, Japan
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Zeng Q, Zhao L, Wang C, Gao M, Han X, Chen C, Tu C, Han P, Li J. Relationship between autoimmune liver disease and autoimmune thyroid disease: a cross-sectional study. Scand J Gastroenterol 2020; 55:216-221. [PMID: 32083943 DOI: 10.1080/00365521.2019.1710766] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: A high prevalence of autoimmune thyroid disease (AITD) has been observed in patients with autoimmune liver disease (AILD); however, data on the clinical relationship between AILD and AITD remain scant. We aimed to evaluate the relationship between AILD and AITD.Methods: We performed a retrospective study using medical records from 324 patients with AILD, 113 of whom had concurrent AITD.Results: Patients with autoimmune hepatitis (AIH) were more likely to develop AITD (45.8%), followed by autoimmune hepatitis-primary biliary cholangitis overlap syndrome (AIH-PBC OS) (39.5%) and PBC (22.6%). Patients with concurrent AILD and AITD showed higher levels of immunoglobulin G (IgG) (21.5 g/L vs 16.3 g/L, p < .0001) and gamma globulin (γ-globulin) (27.1% vs 21.9%, p < .0001). IgG was positively correlated with thyroid antibodies [thymoglobulin antibody (TGAb) and thyroperoxidase antibody (TPOAb)] (r = 0.396, 0.322; p < .0001, p = .002, respectively). TPOAb positivity was highest in PBC patients with concurrent AITD (83.9%). Patients with concurrent PBC and AITD were significantly older than those with PBC alone (p = .0004). Patients with concurrent AIH and AITD had a higher homogenous nuclear pattern of antinuclear antibody positivity compared to those with AIH alone (p = .019). Thyroid dysfunction in AILD patients with concurrent AITD was principally characterized by Hashimoto's thyroiditis (65.5%), and diffuse lesions were mainly found by thyroid ultrasound (53.1%).Conclusions: The high incidence of AILD concomitant with AITD, the higher levels of serum IgG and γ-globulin, and the strong correlation between thyroid antibodies and IgG suggest that close screening for AITD and accurate physical examinations should be performed for all patients with AILD.
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Affiliation(s)
- Qingmin Zeng
- Department of Hepatology, Tianjin Medical University, Tianjin Second People's Hospital, Tianjin, China
| | - Lili Zhao
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin Institute of Hepatology, Tianjin, China
| | - Chunyan Wang
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin Institute of Hepatology, Tianjin, China
| | - Min Gao
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin Institute of Hepatology, Tianjin, China
| | - Xu Han
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin Institute of Hepatology, Tianjin, China
| | - Chen Chen
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin Institute of Hepatology, Tianjin, China
| | - Chunhua Tu
- Department of Infectious Diseases, First Hospital of Medical College of Shantou University, Guangdong, China
| | - Ping Han
- Department of Hepatology, Tianjin Second People's Hospital, Tianjin Institute of Hepatology, Tianjin, China
| | - Jia Li
- Department of Hepatology, Tianjin Medical University, Tianjin Second People's Hospital, Tianjin, China.,Department of Hepatology, Tianjin Second People's Hospital, Tianjin Institute of Hepatology, Tianjin, China
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Muratori P, Lenzi M, Cassani F, Lalanne C, Muratori L. Diagnostic approach to autoimmune hepatitis. Expert Rev Clin Immunol 2017; 13:769-779. [PMID: 28480763 DOI: 10.1080/1744666x.2017.1327355] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease which, if left without treatment, can evolve into cirrhosis and possibly liver failure. The diagnosis of AIH is hampered by the lack of specific and reliable markers of the disease and a number of clinical, biochemical, immunological, histological and genetic factors should be considered to reach a confident diagnosis Areas covered: Clinical expression of AIH, histological features, serological and genetic profiles, differential diagnosis, overlap with other autoimmune liver diseases, assessed on the basis of personal experience and review of published literature in the last 10 years through a systematic Medline search (keywords: autoimmune hepatitis, diagnosis) Expert commentary: Notwithstanding numerous efforts to identify simple and reliable markers of the disease, the diagnosis of AIH is still based on the combination of histological, immunological and biochemical features and often can represent a real challenge for the hepatologist.
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Affiliation(s)
- Paolo Muratori
- a Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System , Policlinico di Sant'Orsola, University of Bologna , Bologna , Italy
| | - Marco Lenzi
- a Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System , Policlinico di Sant'Orsola, University of Bologna , Bologna , Italy
| | - Fabio Cassani
- a Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System , Policlinico di Sant'Orsola, University of Bologna , Bologna , Italy
| | - Claudine Lalanne
- a Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System , Policlinico di Sant'Orsola, University of Bologna , Bologna , Italy
| | - Luigi Muratori
- a Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System , Policlinico di Sant'Orsola, University of Bologna , Bologna , Italy
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Wong GW, Yeong T, Lawrence D, Yeoman AD, Verma S, Heneghan MA. Concurrent extrahepatic autoimmunity in autoimmune hepatitis: implications for diagnosis, clinical course and long-term outcomes. Liver Int 2017; 37:449-457. [PMID: 27541063 DOI: 10.1111/liv.13236] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 08/13/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND Concurrent extrahepatic autoimmune disease (CEHAID) associated with autoimmune hepatitis (AIH) have been incorporated into the diagnostic criteria stipulated by the International Autoimmune Hepatitis Group (IAIHG). Large comprehensive cohort data on the extrahepatic autoimmunity in AIH remain scanty. AIM To systematically assess features and clinical impact of CEHAID on AIH. METHODS Clinical records of 562 patients with AIH from two tertiary centres in the UK were retrospectively reviewed. RESULTS Prevalence of CEHAID in patients with AIH was 42%. Autoimmune thyroid disease was the commonest CEHAID associated with AIH (101/562, 18%). Autoimmune skin diseases were more prevalent in AIH-2 than AIH-1 (21.9% vs 7%, P=.009). Personal history of CEHAID was more commonly found in AIH patients with than without first-degree family history of CEHAID [48/86 (55.8%) vs 169/446 (37.9%), P=.002]. AIH patients with CEHAID were more often women (85.2% vs 76.1%, P=.008), had higher post-treatment IAIHG score (22 vs 20, P<.001), less reactivity to smooth muscle antibodies (49.8% vs 65%, P<.001), more likely to have mild fibrosis at diagnosis (20.9% vs 6.5%, P<.001) and less often had ascites (6.3% vs 13.6%, P=.008) and coagulopathy (1.18 vs 1.27, P=.013) at presentation. Presence of CEHAID, however, did not significantly affect disease progression, prognosis and survival in AIH. CONCLUSIONS Our study confirms the strong association of CEHAID with AIH. Association between personal and familial extrahepatic autoimmunity especially among first-degree relatives was evident. Presence of CEHAID may influence clinical phenotype of AIH at presentation, but without notable impact on the long-term clinical outcomes.
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Affiliation(s)
- Guan-Wee Wong
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Tian Yeong
- Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - David Lawrence
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital, Brighton, UK
| | - Andrew D Yeoman
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Sumita Verma
- Department of Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital, Brighton, UK
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Abstract
AIM To assess the frequency and clinical impact of associated extrahepatic autoimmune diseases (EAD) on autoimmune liver diseases (ALD). PATIENTS AND METHODS We investigated 608 patients with ALD (327 autoimmune hepatitis - AIH and 281 primary biliary cirrhosis - PBC) for concomitant EAD. RESULTS In both AIH and PBC, we observed a high prevalence of EAD (29.9 and 42.3%, respectively); both diseases showed a significant association with autoimmune thyroid disease, followed by autoimmune skin disease, celiac disease, and vasculitis in AIH patients and sicca syndrome, CREST syndrome, and celiac disease in PBC patients. At diagnosis, AIH patients with concurrent EAD were more often asymptomatic than patients with isolated AIH (P<0.01). CONCLUSION Our study confirms the strict association between ALD and EAD, in particular with autoimmune thyroid disease. In the light of our results, all patients with an EAD should be assessed for the concomitant presence of an asymptomatic ALD.
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Hamamoto K, Inaba M, Yamada S, Yoda M, Yoda K, Goto H, Kurajoh M, Koyama H. Increased soluble IL-2 receptor levels in serum from a patient with painless thyroiditis. Thyroid Res 2013; 6:12. [PMID: 24305463 PMCID: PMC3892017 DOI: 10.1186/1756-6614-6-12] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 11/22/2013] [Indexed: 12/05/2022] Open
Abstract
Context Serum concentration of soluble interleukin-2 receptor (sIL-2R) has been established as a reliable marker of T-lymphocyte activation. However, there have been no reports describing the relationship between serum sIL-2R and painless thyroiditis. Objective We report a case of a 76-yr-old female with a significant and temporary increase of sIL-2R concomitant with painless thyroiditis. Case illustration The patient was diagnosed with malignant lymphoma at the age of 73. After 6 cycles of CHOP-R complete remission was induced and no recurrence was observed up to 3.5 years. At 76 years of age, she exhibited hyperthyroidism and was diagnosed with painless thyroiditis based upon US examination and 99mTc-Thyroid scintigraphy. Her AST and ALT were mildly elevated, and her serum level of sIL-2R increased up to 2230 U/mL from the approximately 540 U/mL, which had been stable for 3 years before. These abnormal data normalized without requiring any treatment. The time-course of the reduction in sIL-2R did not correlate with FT4 or FT3, but was very similar to that of AST and ALT. Conclusion There was no evidence of relapse of the malignant lymphoma. We conclude that the increase of sIL-2R was associated with painless thyroiditis. Considering the similar time-course between the reduction of serum sIL-2R and those of AST and ALT, which are often accompanied by autoimmune processes in painless thyroiditis during the development of hyperthyroidism, it was suggested that the increase of serum sIL-2R in this case resulted from activation of an autoimmune process.
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Affiliation(s)
| | - Masaaki Inaba
- Department of Nephrology, Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
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Abstract
BACKGROUND Jaundice and hepatic dysfunction have been reported in patients with thyrotoxicosis and could be due to different mechanisms. OBJECTIVE To describe three cases of jaundice occurring in patients with thyrotoxicosis and to illustrate the importance of early institution of thionamides when indicated. METHODS We present the clinical and laboratory features of three patients presenting within a year with thyrotoxicosis and jaundice and whose clinical conditions improved remarkably following treatment with thionamides. In addition, current literature on the subject is reviewed and summarised. RESULTS The three patients presented with goitre and jaundice. None of the patients had received blood products, undergone scarification markings or experienced any previous episode of jaundice. Thyroid function tests in the three patients were consistent with a diagnosis of thyrotoxicosis. Liver function tests showed elevated bilirubin and transaminases. All patients improved remarkably following treatment with thionamides. CONCLUSION It is important to rule out thyrotoxicosis in patients with jaundice of unknown cause and consider early use of thionamides for treatment of the thyrotoxicosis, if confirmed.
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Affiliation(s)
- T O Akande
- Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
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de Campos Mazo DF, de Vasconcelos GBS, Pereira MAA, de Mello ES, Bacchella T, Carrilho FJ, Cançado ELR. Clinical spectrum and therapeutic approach to hepatocellular injury in patients with hyperthyroidism. Clin Exp Gastroenterol 2013; 6:9-17. [PMID: 23550044 PMCID: PMC3579408 DOI: 10.2147/ceg.s39358] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Liver dysfunction in patients with hyperthyroidism includes abnormalities associated with the effects of thyroid hormone excess, those secondary to drug-induced liver injury, and changes resulting from concomitant liver disease. Our goal was to describe clinical, biochemical, and histopathological patterns in patients suffering from hyperthyroidism and concomitant liver dysfunction and to propose an algorithm of procedures to facilitate diagnosis and management of such cases. This study describes seven patients with liver biochemistry abnormalities detected after diagnosis of hyperthyroidism and one with undiagnosed decompensated hyperthyroidism and acute hepatitis. Two patients showed autoantibody reactivity which, together with liver histology, suggested the diagnosis of classic autoimmune hepatitis. Three patients experienced hepatotoxicity induced by propylthiouracil, the manifestations of which ranged from a benign course after drug withdrawal in one, a longstanding course in another suggesting drug-induced autoimmune hepatitis, and a more severe clinical condition with acute liver failure in a third patient, requiring liver transplantation. The three remaining patients showed no precipitating factors other than thyroid hyperactivity itself. They could be interpreted as having a thyroid storm with different clinical presentations. In conclusion, this series of patients illustrates the most frequent patterns of hepatocellular damage associated with hyperthyroidism and provides an algorithm for their diagnosis and treatment.
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Affiliation(s)
- Daniel Ferraz de Campos Mazo
- Department of Gastroenterology, Institute of Tropical Medicine, University of São Paulo School of Medicine, São Paulo, Brazil
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Autoimmune hepatitis as a part of polyglandular autoimmune syndrome type II: case report and literature review. Dig Dis Sci 2010; 55:861-4. [PMID: 19421855 DOI: 10.1007/s10620-009-0796-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Accepted: 03/17/2009] [Indexed: 12/09/2022]
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Abstract
BACKGROUND Although the pathomechanisms of autoimmune diseases in various organs remain unresolved, an accumulation of autoimmune diseases in individual patients has been observed. An overlap of autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC) or primary sclerosing cirrhosis has been well documented. However, the overlap of autoimmune diseases other than PBC or PSC has not yet been investigated in a large cohort. GOAL The goal of our analysis was to investigate the incidence of concurrent autoimmune diseases in patients with AIH. STUDY We analyzed our cohort of 278 patients with AIH for concurrent autoimmune diseases. RESULTS A total of 111 patients (40%) were diagnosed with additional autoimmune diseases. Besides overlap syndromes for PBC and PSC, autoimmune thyroiditis was the most common concurrent disease (28 patients, 10%). Other concurrent autoimmune diseases comprised vitiligo (5 patients), rheumatoid arthritis (5 patients), Sjogren syndrome (4 patients), ulcerative colitis (4 patients), conjunctivitis (4 patients), celiac disease (3 patients), systemic lupus erythematodes (2 patients), type I diabetes (2 patients), multiple sclerosis (2 patients), polymyalgia rheumatica (2 patients), and urticaria (2 patients). One patient each was diagnosed with Crohn's disease, autoimmune gastritis, collagenous colitis, hypophysitis, and sarcoidosis. Investigating 100 patients with polyglandular syndrome and autoimmune thyroid disease for the occurrence of autoantibodies associated with AIH, we identified AIH-associated antibodies only in 1 patient. CONCLUSIONS Concurrent autoimmune diseases are common in patients with AIH and mirror the full range of known autoimmune diseases. Therefore, an extended diagnostic screening for accumulating autoimmune diseases, especially autoimmune thyroiditis, seems reasonable in patients with AIH.
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Chen WC, Zhu ZX, Wang CH, Chien MN. Cholestasis and Acute Cholecystitis in Hyperthyroidism Treated With Methimazole. INT J GERONTOL 2009. [DOI: 10.1016/s1873-9598(10)70009-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Abstract
Patients with jaundice of unknown cause need their thyroid function tested to exclude an underlying thyroid problem
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Affiliation(s)
- P J D Owen
- Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Cardiff.
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