Thyroid storm presenting with liver failure

Case Report: A Sudden Thyroid-Related Death of a 15-Year-Old Girl

A 15-year-old young girl was found dead at home. There were no indications of any intervention or the application of force. On the previous day, she was admitted to hospital because of palpitations, fatigue, a headache, and a swollen neck. During a physical examination, a swollen thyroid gland and tachycardia were found. In the family history, her mother had thyroid disease. According to the laboratory values, she had elevated thyroid hormone levels. After administration of beta-blockers, the patient was discharged and died at home during the night. The parents denounced the hospital for medical malpractice; therefore, a Forensic Autopsy was performed. Based on the available clinical data, the autopsy, histological and toxicological results, the cause of death was stated as multiorgan failure due to disseminated intravascular coagulation (DIC) caused by the autoimmune Graves disease. The forensic assessment of the case does not reveal medical malpractice. Post-mortem diagnoses of thyroid disorders in cases of sudden death can be challenging. However, as the reported case illustrates, the diagnosis could be established after a detailed evaluation of antemortem clinical data, autopsy results, histology, and a toxicological examination.

Characteristics of Graves' disease in children and adolescents in Nanjing: A retrospective investigation study

Objective

This cross-sectional study analyzed the clinical characteristics of newly diagnosed Graves' disease (GD) in children and adolescents to provide clinical evidence for the early diagnosis of GD.

Method

From 2013 to 2019, information on children and adolescents with newly diagnosed GD admitted to the Department of Endocrinology, Children's Hospital of Nanjing Medical University, was collected, including clinical features and laboratory tests. The data were summarized and statistically analyzed.

Result

This study included 204 cases of newly diagnosed GD, with 158 females and 46 males. The average age at initial diagnosis was 8.9 ± 2.9 years. A total of 132 cases (64.7%) had symptoms before puberty, and 72 cases (35.3%) had symptoms during puberty. Goiter was detected in 193 cases (94.6%). There were 140 cases (68.6%) of exophthalmos, and 21.4% (30/140) were infiltrative. At initial diagnosis, 10 cases (4.9%) reported leukopenia, 18 cases (8.8%) reported neutropenia, and 15 cases (7.4%) reported mild anemia. There was 1 (0.5%) case of thrombocytopenia and 1 (0.5%) case of agranulocytosis. Fifty-four cases (26.5%) had impaired liver function.

Conclusion

GD is more common in female children and adolescents. Parents may ignore their children's hypermetabolic symptoms in the early stages of GD. Routine blood and liver function tests are recommended at initial diagnosis to exclude abnormal hemogram and liver function.

Severe hyperthyroidism without symptoms due to nonthyroidal illness in a child with acute hepatitis: case report and literature review

While liver enzyme changes are frequently reported in hyperthyroidism, liver dysfunction itself can lead to alterations in thyroid hormone metabolism. However, the exact relationship between hyperthyroidism and liver dysfunction is unclear. We report an 11-year-old boy presenting with acute hepatitis of unknown etiology, who was incidentally found to have asymptomatic biochemical hyperthyroidism. Despite significant total and free T4 elevation, clinical evidence of thyrotoxicosis was absent. Thyroid I-123 uptake was also reduced. Additional testing revealed slight T3 elevation and significant rT3 elevation. Graves' and Hashimoto's thyroiditis testing was negative. We hypothesize that the biochemical hyperthyroidism was due to transient thyroiditis. Although an etiology for the boy's hepatitis was never determined, and an undiagnosed infectious etiology causing subacute thyroiditis was considered, subsequent testing showing positive thyroid peroxidase antibodies, suggesting autoimmune Hashimoto's thyroiditis as the likely cause of the hyperthyroidism. We believe, furthermore, that the absence of symptoms was the result of concurrent nonthyroidal illness resulting in the biochemical findings of slight T3 elevation and significant rT3 increase despite significant T4 elevation.

The interplay between thyroid and liver: implications for clinical practice

A complex relationship exists between thyroid and liver in health and disease. Liver plays an essential physiological role in thyroid hormone activation and inactivation, transport, and metabolism. Conversely, thyroid hormones affect activities of hepatocytes and hepatic metabolism. Serum liver enzyme abnormalities observed in hypothyroidism may be related to impaired lipid metabolism, hepatic steatosis or hypothyroidism-induced myopathy. Severe hypothyroidism may have biochemical and clinical features, such as hyperammonemia and ascites, mimicking those of liver failure. Liver function tests are frequently abnormal also in hyperthyroidism, due to oxidative stress, cholestasis, or enhanced osteoblastic activity. Antithyroid drug-associated hepatotoxicity is a rare event, likely related mainly to an idiosyncratic mechanism, ranging from a mild hepatocellular damage to liver failure. Propylthiouracil-induced liver damage is usually more severe than that caused by methimazole. On the other hand, thyroid abnormalities can be found in liver diseases, such as chronic hepatitis C, liver cirrhosis, hepatocellular carcinoma, and cholangiocarcinoma. In particular, autoimmune thyroid diseases are frequently found in patients with hepatitis C virus infection. These patients, especially if thyroid autoimmunity preexists, are at risk of hypothyroidism or, less frequently, thyrotoxicosis, during and after treatment with interpheron-alpha alone or in combination with ribavirin, commonly used before the introduction of new antiviral drugs. The present review summarizes both liver abnormalities related to thyroid disorders and their treatment, and thyroid abnormalities related to liver diseases and their treatment.

Yinning Tablet, a hospitalized preparation of Chinese herbal formula for hyperthyroidism, ameliorates thyroid hormone-induced liver injury in rats: Regulation of mitochondria-mediated apoptotic signals

ETHNOPHARMACOLOGICAL RELEVANCE

Hyperthyroidism is closely associated with liver injury. The preliminary clinical observation suggests that Yinning Tablet, a hospitalized preparation of traditional Chinese formula for hyperthyroidism, improves not only hyperthyroidism, but also hyperthyroidism-associated liver injury.

AIM

To evaluate the effect and underlying mechanisms of Yinning Tablet on thyroid hormone-induced liver injury.

MATERIALS AND METHODS

Female rats were orally administered L-thyroxine (1 mg/kg) once daily for 60 days, and co-treated with the carefully identified Yinning Tablet extract (0.6-2.4 g/kg) during the last 30 days. Blood and liver variables were determined enzymatically, histologically, by ELISA, radioimmunoassay, Real-Time PCR or Western blot, respectively.

RESULTS

Co-treatment with the extract attenuated L-thyroxine-induced increases in serum alanine transaminase and aspartate transaminase activities, the ratio of liver weight to body weight, cytoplasmic vacuolization in hepatocytes, infiltrated inflammatory cells and confused structures in liver tissue, accompanied by attenuation of increased serum triiodo-l-thyronine concentration and hepatic deiodinase type I overexpression in rats. Importantly, Yinning Tablet suppressed L-thyroxine-triggered hepatic Bax, cleaved caspases-3, -8 and -9 protein overexpression, and Bcl-2 protein downregulation. Furthermore, the increases in cytochrome c protein expression, Ca²⁺-ATPase activity and malondialdehyde content, and decreases in activities of Na⁺/K⁺-ATPase, catalase, superoxide dismutase and glutathione peroxidase, and total antioxidant capacity in liver tissue were attenuated.

CONCLUSION

The present results suggest that Yinning Tablet ameliorates thyroid hormone-induced liver injury in rats by regulating mitochondria-mediated apoptotic signals. Our findings go insight into the pharmacological basis of the hospitalized preparation for treatment of hyperthyroidism-associated liver injury.

Peripheral blood picture and aminotransferase activity in children with newly diagnosed Graves' disease at baseline and after the initiation of antithyroid drug therapy

Aim of the study

Assessment of the peripheral blood picture and aminotransferase activity in children with newly diagnosed Graves' disease (GD) at baseline and 4-6 weeks after the initiation of antithyroid drug (ATD) therapy.

Material and methods

Data of 59 children were assessed retrospectively. Baseline analysis included concentrations of thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), TSH receptor antibodies (TSH-R Ab), complete blood cell count (CBC), aspartate (AST) and alanine aminotransferase (ALT) activity. Reassessment of CBC and aminotransferase activity was performed 4-6 weeks after the initiation of ATD therapy.

Results

Significant decreases in the neutrophil count, MCV, haemoglobin (Hgb), red blood cell (RBC) count, white blood cell (WBC) count and platelet (PLT) count were found in 37.3%, 32.2%, 22%, 13.6%, 8.5% and 5% of untreated patients, respectively. Increased baseline ALT and AST activity was observed in 44% and 32.2% of children, respectively. Initiation of ATD therapy led to significant changes in Hgb, RBC and PLT count, RDW and ALT activity. Negative associations between TSH-R Ab, TSH and MCV were found. ALT and AST activity were negatively related to baseline TSH levels. ALT activity was also associated with baseline fT4 and fT3.

Conclusions

The incidence of haematopoiesis and liver abnormalities in GD children seems to be similar to that reported in adult patients. The most common alterations are changes in neutrophil count, RBC parameters and ALT activity. The initiation of ATD therapy usually leads to significant improvement in those parameters.

Therapeutic plasma exchange and a double plasma molecular absorption system in the treatment of thyroid storm with severe liver injury: A case report

BACKGROUND

Thyroid storm is resistant to conventional treatments including antithyroid drugs and ¹³¹I therapeutic means. Plasma exchange (PE) and double plasma molecular absorption system (DPMAS) can be used as an effective treatment for thyroid storm with severe liver injury.

CASE SUMMARY

A 52-year-old woman presented with a 10-day history of nausea and vomiting accompanied by yellowing of the skin and mucosa. Further, her free T3 (FT3) and FT4 levels were significantly elevated, whereas her thyrotropin level was reduced. After admission, her condition continued to deteriorate, and she presented with continued high fever, vomiting, palpitation, and shortness of breath. After being diagnosed with thyroid storm, the patient was immediately treated with PE combined with DPMAS. Her symptoms improved immediately. After three PE + DPMAS treatments, and she was discharged from the hospital. She was treated with methylprednisolone and methylthimidazole. After six months, the patient spontaneously discontinued methylthimidazole treatment. Her previous clinical manifestations and liver dysfunction reoccurred. The patient was treated with PE + DPMAS two times, and her condition rapidly improved. Liver histopathology indicated immunological liver injury.

CONCLUSION

Our experience suggests that PE combined with DPMAS can effectively relieve the development of thyroid storm.

Endocrine Diseases and the Liver: An Update

The endocrine system is a complex interconnected system of organs that control corporeal processes and function. Primary endocrine organs are involved in hormonal production and secretion but rely on a bevy of signals from the hypothalamic-pituitary axis and secondary endocrine organs, such as the liver. In turn, proper hepatic function is maintained through hormonal signaling. Thus, the endocrine system and liver are codependent, and diseases affecting either organs can lead to alterations in function within their counterparts. This article explores the hepato-endocrine relationship, including the effects on endocrine diseases on the liver.

Severe cholestatic jaundice associated with Graves' disease

We describe a rare case of Graves' disease presenting with atrial fibrillation and severe cholestasis. An extensive evaluation for hepatobiliary causes of cholestasis, including hepatic biopsy, was entirely negative. He was successfully treated with methimazole and eventual thyroidectomy. With caution, thionamides can be utilized successfully for such patients.

Risk factors of hepatic dysfunction in patients with Graves' hyperthyroidism and the efficacy of 131iodine treatment

Hepatic dysfunction is often observed in patients with Graves' hyperthyroidism. The aims of this study were to investigate the risk factors for hepatic dysfunction and to analyze the efficacy of I (radioactive iodine-131) treatment. In total, 2385 patients with Graves' hyperthyroidism (478 males, 1907 females; age 42.8 ± 13.5 years) were involved in our study. Of these, 1552 cases with hepatic dysfunction received I treatment. All clinical data were retrospectively reviewed to explore the risk factors associated with hepatic dysfunction using logistic regression analysis. Furthermore, we observed thyroid and liver function indices for the 1552 subjects at 3, 6 and 12 months after I treatment, in order to evaluate efficacy. Overall, 65% patients were affected by hepatic dysfunction. The most common abnormality was elevated alkaline phosphatase (ALP), of which the prevalence was 52.3%. The percentages of hepatocellular injury type, bile stasis, and mixed type were 45.8%, 32.4%, and 21.8%, respectively. Both univariate and multivariate analyses demonstrated that age, duration of Graves hyperthyroidism, free triiodothyronine (FT3)level, and thyrotrophin receptor antibody (TRAb) concentration were the most significant risk factors predicting hepatic dysfunction. Additionally, the patients with mild hepatic dysfunction, or hepatocellular injury type were more likely to attain normal liver function after I treatment. Furthermore, after I treatment, liver function was more likely to return to normal in the cured group of patients compared with the uncured group. Older patients and cases with a longer history of Graves' hyperthyroidism, higher FT3 or TRAb concentration were more likely to be associated with hepatic dysfunction, and the prognosis of hepatic dysfunction was closely associated with the outcomes of Graves' hyperthyroidism after I treatment.

Therapeutic Effects of Blue Honeysuckle on Lesions of Hyperthyroidism in Rats

Hyperthyroidism is a hypermetabolic syndrome characterized by an overproduction of thyroid hormones, which enhances the hormone-induced oxidative stress responsible for some complications in the liver, heart and muscle. Blue honeysuckle (BH) is an edible berry, rich in polyphenols, especially flavonoids or anthocyanins, known as strong antioxidants. The chemo-protective activities of the berry have been connected to the improvement of symptoms in cancer, diabetes mellitus, tumor or cardiovascular diseases. Therefore, the therapeutic effects of BH were examined in hyperthyroidism rat model. The hyperthyroidism was induced by injection with levothyroxine (LT4), and the model was treated with distilled water (LT4 control), propylthiouracil (PTU) or BH at 3 dosages of 500, 250 and 125[Formula: see text]mg/kg. The treatment was performed once a day for 15 days. Compared to LT4 control, the oral administration of BH dose-dependently ameliorated the hyperthyroidism, reducing thyroid hormones and increasing thyroid stimulating hormones. These effects were accompanied by improvement of body weight loss and atrophy in the thyroid gland, liver and epididymal fat pads. BH treatments also reduced the levels of hepatic enzymes (AST and ALT), which suggests BH exerts protective effects on hepatocytes. BH might also be involved in the augmentation of the anti-oxidant activities, supported by increased endogenous antioxidant (glutathione). In addition, the histopathological analyses revealed the beneficial effects of BH on the atrophic changes and cellular injuries in the thyroid gland, liver and epididymal fat pads. The therapeutic potentials of BH were either similar or more effective than PTU. These results provide valuable information that will guide more detailed studies to use the BH as a complementary and alternative medicine.

Thyrotoxic Storm

Thyrotoxic storm is a syndrome of exaggerated thyrotoxicosis with systemic decompensation seen in 1-2% of hospital admissions for thyrotoxicosis. The diagnosis is based on recognition of typical cardinal manifestations, but even when diagnosed and treated, mortality rates are high. Results of thyroid function tests may be no more abnormal than those seen in uncomplicated thyrotoxicosis. Often, there is a history of partially treated thyrotoxicosis, and/or decompensation related to a precipitating event such as infection, stroke, pulmonary embolism, or radioiodine therapy. Treatment must be aggressive and includes volume repletion with i.v. glucose and saline, and pressor agents may be needed. Patients belong in an intensive care unit, with a cooling blanket for hyperpyrexia. Appropriate cardiac medications are employed to control ventricular rate in those with atrial fibrillation. The thyroid is blocked by large doses of antithyroid agent. In patients unable to swallow, tablets can be crushed and given by nasogastric tube or per rectum. After antithyroid drugs are started, stable iodine as Lugol's solution is given to block further hormone release from the gland. Sodium ipodate can be used instead of iodine and has the advantage of inhibiting conversion of T4 to T3. In severe cases, thyroid hormone may be removed from the circulation by peritoneal dialysis or plasmapheresis, and cholestyramine resin may be used to bind T4 and T3 within the gastrointestinal tract. β-adrenergic antagonists such as propranolol are given, or the very short-acting β-adrenergic blocker, esmolol, has also been used with success. A Swan-Ganz catheter is used to monitor central hemodynamics, especially in patients receiving high-dose propranolol, pressors, digoxin, diuretics, and fluids. Large doses of dexamethasone have been given based on presumed increased glucocorticoid requirements in thyrotoxicosis and because adrenal reserve may be reduced. Therapy must be continued until a normal metabolic state is achieved, at which time iodine is progressively withdrawn and plans made for definitive treatment.

Thyroid disorders and gastrointestinal and liver dysfunction: A state of the art review

Thyroid disorders commonly impact on the gastrointestinal system and may even present with gastrointestinal symptoms in isolation; for example, metastatic medullary thyroid carcinoma typically presents with diarrhoea. Delays in identifying and treating the underlying thyroid dysfunction may lead to unnecessary investigations and treatment, with ongoing morbidity, and can potentially be life-threatening. Similarly, gastrointestinal diseases can impact on thyroid function tests, and an awareness of the concept and management of non-thyroidal illness is necessary to avoid giving unnecessary thyroid therapies that could potentially exacerbate the underlying gastrointestinal disease. Dual thyroid and gastrointestinal pathologies are also common, with presentations occurring concurrently or sequentially, the latter after a variable time lag that can even extend over decades. Such an association aetiologically relates to the autoimmune background of many thyroid disorders (e.g. Graves' disease and Hashimoto's thyroiditis) and gastrointestinal disorders (e.g. coeliac disease and inflammatory bowel disease); such autoimmune conditions can sometimes occur in the context of autoimmune polyglandular syndrome. Emphasis should also be given to the gastrointestinal side effects of some of the medications used for thyroid disease (e.g. anti-thyroid drugs causing hepatotoxicity) and vice versa (e.g. interferon therapy causing autoimmune thyroid dysfunction). In this review, we discuss disorders of the thyroid-gut axis and identify the evidence base behind the management of such disorders.

Severe acute liver failure and thyrotoxicosis: an unusual association

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.

Factors predicting abnormal liver function tests induced by Graves' disease alone: a retrospective cohort study

Abnormal liver function tests (LFTs) are often observed in patients with Graves' disease (GD). To date, there are limited data demonstrating the factors or biochemical indexes contributing to LFT abnormalities in this patient population. The aim of this study was to explore factors predicting abnormal LFTs induced by GD alone. This was a retrospective study of 289 consecutive cases of newly diagnosed and untreated patients with GD. All patients were divided into abnormal LFTs (group A) and normal LFTs (group B). In total, 205 (70.9%) cases were found to have at least 1 LFT abnormality. Among them, the frequencies of ALT, AST, ALP, γ-GTP, TBIL and DBIL abnormalities were 52.7%, 32.2%, 45.9%, 38.5%, 23.4%, 2.9%, respectively, and the number of patients with 1 to 6 hepatic variable abnormalities were 89, 64, 30, 16, 6 and 0, respectively. Logistic regression analysis was used to determine predictive factors contributing to abnormal LFTs. A receiver operating characteristic (ROC) curve was also plotted to verify the accuracy of predictors. In the univariate analysis, patients in group A had significantly higher FT3 concentration (37.5 vs 33.4 pmol/L, P = 0.009), FT4 concentration (85.7 vs 77.4 pmol/L, P = 0.002) and TRAb level (22.2 vs 17.4 IU/L, P < 0.001) when compared with those in group B. Binary logistic regression analysis identified higher FT4 concentration (odds ratio [OR]: 1.017, 95% confidence interval [CI]: 1.005-1.030, P = 0.006) and higher TRAb value (OR: 1.038, 95% CI:1.013-1.064, P = 0.003) to be independent risk factors predicting abnormal LFTs. The optimal cutoffs for FT4 and TRAb to predict abnormal LFTs were 75 pmol/L and 15 IU/L, respectively, based on ROC analysis.

Liver dysfunction and anti-thyroid therapy

Thioamides have been used in the management of hyperthyroidism for over 50 years. Liver dysfunction is a rare but important side effect associated with their use. Recently, cases of liver failure associated with propylthiouracil have prompted the Federal Drug Administration to issue a Boxed Warning to the label of propylthiouracil regarding its risk of potentially fatal liver injury and acute liver failure in adults and children. Herein, we present a case to underline the importance of recognising the similar potential for severe hepatic dysfunction with the use of other thioamides.

Grave's Disease with Severe Hepatic Dysfunction: A Diagnostic and Therapeutic Challenge

Hepatic dysfunction in a patient with thyrotoxicosis may result from hyperthyroidism per se, as a side effect of antithyroid drugs, and causes unrelated to hyperthyroidism which sometimes causes diagnostic and therapeutic difficulties. A young female patient was admitted to our hospital with symptoms of thyrotoxicosis, diffuse goiter and ophthalmopathy along with cholestatic pattern of jaundice, and proximal muscle weakness. She was treated with propylthiouracil with gradual recovery. She was continuing her antithyroid medication with regular follow-up. The patient was readmitted a few months later with worsening thyrotoxicosis, proximal muscle weakness, fever, and a hepatocellular pattern of jaundice with sepsis. Propylthiouracil was stopped and lithium along with steroid coverage was given to control her thyrotoxicosis which was later changed to methimazole. Broad spectrum antibiotic therapy was also started but without any response. During her hospital stay, the patient also developed a flaccid paraplegia resembling Guillain-Barre syndrome. IV steroid was started for the neuropathy but meanwhile the patient succumbed to her illness. So in centers where facility for radioiodine therapy is not readily available, some definite well-tested protocols should be formulated to address such common but complicated clinical situations.

Cholestasis and protein-losing enteropathy secondary to hyperthyroidism in a 6-year-old girl

Hepatic dysfunctions are not infrequent in patients with hyperthyroidism. These disorders may be related to the effects of the excess thyroid hormone secretion, to the uses of antithyroid drugs, or to the presence of concomitant hepatic diseases. Our aim is to describe the clinical and biochemical features of liver dysfunction related to thyrotoxicosis. We report here a case of a 6-year-old girl who was admitted for jaundice and pruritus as a result of the development of hyperthyroidism due to Graves' disease. On physical examination at admission, she was found to have jaundice and hepatomegaly. Laboratory data show cholestasis and protein-losing enteropathy. Investigations exclude other causes of hepatic disorder. One month after the initiation of antithyroid drug, the patient became euthyroid with improvement in jaundice and pruritus and normalization of hepatic tests and alpha antitrypsine clearance. In conclusion, the diagnosis of hyperthyroidism may be delayed in patients in whom the primary manifestations were pruritus and jaundice. The physician should suspect thyrotoxicosis prior to hepatitis or skin manifestations.

Increased risk of hepatobiliary cancers after hospitalization for autoimmune disease

BACKGROUND & AIMS

Some autoimmune diseases are associated with increased risk of liver cancer. However, there has been no comprehensive evaluation of autoimmune diseases among patients who develop different subtypes of hepatobiliary cancer. We examined the association between autoimmune diseases and cancers of the liver and biliary tract in the Swedish population.

METHODS

We analyzed data from national datasets at the Center for Primary Health Care Research (Lund University, Sweden). Data on patients with autoimmune disorders were retrieved from the Swedish Hospital Discharge Register, from 1964 through 2008; 33 diseases were evaluated. Hepatobiliary cancer cases were retrieved from the Swedish Cancer Registry. We calculated standardized incidence ratios (SIRs) and hazard ratios for incident cancers and deaths from hepatobiliary cancers.

RESULTS

Among 402,462 patients with autoimmune disorders, 582 were diagnosed with primary liver cancer, 330 with gallbladder cancer, 115 with extrahepatic bile duct cancer, and 43 with ampulla of Vater cancers. We identified 14 autoimmune conditions that were significantly associated with increased risk of primary liver cancer (overall SIR [any autoimmune disease], 2.1; 95% confidence interval [CI], 2.0-2.3), 5 conditions associated with gallbladder cancer (overall SIR, 1.3; 95% CI, 1.1-1.4), and 3 associated with extrahepatic bile duct cancer (overall SIR, 1.6; 95% CI, 1.3-1.9). The autoimmune disorders with the strongest association with primary liver cancer were primary biliary cirrhosis (SIR, 39.5; 95% CI, 28.2-53.8) and autoimmune hepatitis (SIR, 29.0; 95% CI, 9.1-68.2); ulcerative colitis was strongly associated with extrahepatic bile duct cancer (SIR, 5.6; 95% CI, 3.6-8.4). Celiac disease, Crohn's disease, systemic sclerosis, and ulcerative colitis were associated with at least 2 types of cancer. Increased hazard ratios were observed only for patients with biliary tract cancer who had been hospitalized for autoimmune conditions.

CONCLUSIONS

In a study of the Swedish population, we identified an increased risk of hepatobiliary cancers among individuals diagnosed with autoimmune disease. Associations among different cancer types indicate that shared immunomodulatory mechanisms determine susceptibility to hepatobiliary cancer.

Clinical concepts on thyroid emergencies

OBJECTIVE

Thyroid-related emergencies are caused by overt dysfunction of the gland which are so severe that require admission to intensive care units (ICU) frequently. Nonetheless, in the ICU setting, it is crucial to differentiate patients with non-thyroidal illness and alterations in thyroid function tests from those with intrinsic thyroid disease. This review presents and discusses the main etiopathogenetical and clinical aspects of hypothyroid coma (HC) and thyrotoxic storm (TS), including therapeutic strategy flow-charts. Furthermore, a special chapter is dedicated to the approach to massive goiter, which represents a surgical thyroid emergency.

DATA SOURCE

We searched the electronic MEDLINE database on September 2013. Data Selection and Data Extraction: Reviews, original articles, and case reports on "myxedematous coma," "HC," "thyroid storm," "TS," "massive goiter," "huge goiter," "prevalence," "etiology," "diagnosis," "therapy," and "prognosis" were selected.

DATA SYNTHESIS AND CONCLUSION

Severe excess or defect of thyroid hormone is rare conditions, which jeopardize the life of patients in most cases. Both HC and TS are triggered by precipitating factors, which occur in patients with severe hypothyroidism or thyrotoxicosis, respectively. The pillars of HC therapy are high-dose l-thyroxine and/or tri-iodothyroinine; i.v. glucocorticoids; treatment of hydro-electrolyte imbalance (mainly, hyponatraemia); treatment of hypothermia; often, endotracheal intubation and assisted mechanic ventilation are needed. Therapy of TS is based on beta-blockers, thyrostatics, and i.v. glucocorticoids; eventually, high-dose of iodide compounds or lithium carbonate may be of benefit. Surgery represents the gold standard treatment in patients with euthyroid massive nodular goiter, although new techniques - e.g., percutaneous laser ablation - are helpful in subjects at high surgical risk or refusing operation.

Thyroid Storm Complicated by Fulminant Hepatic Failure: Case Report and Literature Review

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.

Thyroid Storm

Thyroid storm, an endocrine emergency first described in 1926, remains a diagnostic and therapeutic challenge. No laboratory abnormalities are specific to thyroid storm, and the available scoring system is based on the clinical criteria. The exact mechanisms underlying the development of thyroid storm from uncomplicated hyperthyroidism are not well understood. A heightened response to thyroid hormone is often incriminated along with increased or abrupt availability of free hormones. Patients exhibit exaggerated signs and symptoms of hyperthyroidism and varying degrees of organ decompensation. Treatment should be initiated promptly targeting all steps of thyroid hormone formation, release, and action. Patients who fail medical therapy should be treated with therapeutic plasma exchange or thyroidectomy. The mortality of thyroid storm is currently reported at 10%. Patients who have survived thyroid storm should receive definite therapy for their underlying hyperthyroidism to avoid any recurrence of this potentially fatal condition.

Clinical spectrum and therapeutic approach to hepatocellular injury in patients with hyperthyroidism

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.

Acute liver failure with thyrotoxicosis treated with liver transplantation

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.

Hepatic dysfunction in hospitalized patients with acute thyrotoxicosis: a decade of experience

Thyroid disease is a common condition, and thyroid hormone excess or deficiency is known to have wide-ranging effects on a variety of organ systems. Our objective is to describe the magnitude, biochemical features, and clinical characteristics of hepatic abnormalities in patients with acute thyrotoxicosis. We performed a retrospective review of all patients admitted to our institution between January 1, 1998 and December 31, 2008 with a discharge diagnosis of acute thyrotoxicosis excluding iatrogenic causes. The records of these patients were reviewed and data extracted regarding demographic, biochemical, and clinical data particularly relevant to liver function. Fourteen patients were identified of which eleven had liver studies performed. The majority (90.9%) had Graves disease. Nine of eleven patients (81.8%) had some degree of hepatic abnormality. Seven patients (63.6%) had an elevation in one or both transaminases, and two (18.2%) had isolated synthetic dysfunction as manifested as an elevated INR and/or decreased albumin without transaminitis. The mean magnitude of deviation from the normal range was greater in the transaminases as compared to bilirubin, INR, or albumin. Definitive treatment was radioiodine ablation in six cases (54.5%) and surgical thyroidectomy in two cases (18.2%). Noniatrogenic acute thyrotoxicosis requiring hospitalization is a rare condition which is most frequently caused by Graves disease. The majority of patients have disordered liver tests of a highly variable nature, making the recognition of this association important in the care of patients presenting with acute thyrotoxicosis.

Surviving the storm: two cases of thyroid storm successfully treated with plasmapheresis

Thyroid storm is a rare, but critical, illness that can lead to multiorgan failure and carries a high death rate. The following case series describes two adult men with Graves' disease who presented in thyroid storm and either failed or could not tolerate conventional medical management. However, both patients responded well to plasmapheresis, which resulted in clinical and biochemical stabilisation of their disease processes. The treatment option of plasmapheresis should be considered as a stabilising measure, especially when patients have failed or cannot tolerate conventional therapy. Plasmapheresis leads to amelioration of symptoms and a significant decline in thyroid hormone levels, providing a window to treat definitively with thyroidectomy.

Cholestatic hepatic injury due to a thyroid storm: a case report from a resource limited setting

INTRODUCTION

Thyroid storm is an endocrinological emergency caused by an exacerbation of the hyperthyroid state and is characterized by multi organ dysfunction. Liver dysfunction or injury predominantly of a cholestatic type is one of the atypical manifestations of thyroid storm and has been previously described in literature. However, there have been few published case reports among African patients and from resource limited settings.

CASE REPORT

We report a case of a 21 year old Ugandan female patient who presented with a thyroid storm due to untreated Graves' disease complicated by cholestatic hepatic injury, congestive heart failure and acute kidney injury.

CONCLUSION

This case highlights the varied multi organ dysfunctions seen in a patient with thyroid storm with emphasis on liver injury mainly to increase awareness among clinicians in resource limited settings. Mechanisms of liver injury due to thyroid storm or hyperthyroidism are discussed in the literature review.

Multiorgan dysfunction accompanied with metimazole and thyroid storm

A 41-year-old man with a history of hyperthyroidism had been treated with methimazole and propranolol for the past 2 months. He developed multiorgan dysfunction with acute liver failure, severe lactic acidosis, disseminated intravascular coagulation, heart failure and acute pulmonary edema with rapid deterioration of renal function. The patient had no history of alcoholism, drug abuse, blood transfusion, or exposure to hepatitis A, B, or C. Extrahepatic obstruction was ruled out with an abdominal ultrasonogram. Serologic studies and immunologic tests were negative. This case illustrates the sudden and abrupt deterioration of multiorgan dysfunction due to antithyroid drug administration and thyroid storm. The thyroid storm score of Burch and Wartofsky was 90/140. The multiorgan dysfunction was reversed by discontinuation of the methimazole and treat with hemodialysis, steroids, cholestyramine, nonselective beta-blocker, fresh frozen plasma infusion and supportive management in the intensive care unit. The patient was discharged from the hospital with normal coagulation parameters, renal and liver function tests.

Endocrine diseases and the liver

Liver disease and endocrine disorders, both common in the general population, have a bidirectional and complex relationship. Certain liver diseases are more commonly associated with endocrine disorders, including nonalcoholic fatty liver disease, autoimmune hepatitis, and primary biliary cirrhosis. There may be an association between hepatitis C and type 2 diabetes mellitus as well as thyroid disorders, and sex hormonal preparations may cause specific hepatic lesions. The presence of relative adrenal insufficiency in patients with end-stage liver disease may have therapeutic implications in patients admitted with acute-on-chronic liver failure. The objective of this review is to focus on the effect of endocrine disorders on liver.

Thyroid storm in a patient with fulminant hepatic failure

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.

Thyroid storm with multiorgan failure

BACKGROUND

Thyroid storm is a rare and potentially fatal condition. Various unusual presentations in patients with thyroid storm have been described but multiorgan dysfunction is uncommonly seen.

SUMMARY

We describe a 35-year-old patient with a history of Graves' disease who was diagnosed with thyroid storm at 2 weeks postpartum. This was complicated by acute liver failure, acute kidney injury, severe lactic acidosis, disseminated intravascular coagulation, and heart failure with acute pulmonary edema. The multiorgan dysfunction was reversed by prompt institution of antithyroid drugs and supportive management in the intensive care unit.

CONCLUSION

Thyroid storm is a medical emergency. One of the challenges lies in recognizing its varied presentations. Early diagnosis and appropriate treatment is important to prevent the catastrophic outcomes associated with this condition.

Hepatic failure resulting from thyroid storm with normal serum thyroxine and triiodothyronine concentrations

A 63-year-old male presented with productive cough, fever, palpitation, shortness of breath, and mental confusion. Fulminant hepatic failure occurred with high aminotransferase and severe jaundice. Thyroid function tests showed thyroid-stimulating hormone level of 0.7 microU/mL (normal range, < 6.2 microU/mL), with normal serum thyroxine and triiodothyronine levels. He died on post-admission day 5. Autopsy revealed diffuse hyperplasia of the thyroid gland, centrilobular necrosis of the liver, and congestion of the gastrointestinal tract, spleen, and adrenal glands. These pathological findings were compatible with decompensated hyperthyroidism. Thyroid storm may present with normal serum triiodothyronine, thyroxine, and hepatic failure. Such presentation is rare.

Consequences of dysthyroidism on the digestive tract and viscera

Thyroid hormones define basal metabolism throughout the body, particularly in the intestine and viscera. Gastrointestinal manifestations of dysthyroidism are numerous and involve all portions of the tract. Thyroid hormone action on motility has been widely studied, but more complex pathophysiologic mechanisms have been indicated by some studies although these are not fully understood. Both thyroid hormone excess and deficiency can have similar digestive manifestations, such as diarrhea, although the mechanism is different in each situation. The liver is the most affected organ in both hypo- and hyperthyroidism. Specific digestive diseases may be associated with autoimmune thyroid processes, such as Hashimoto’s thyroiditis and Grave’s disease. Among them, celiac sprue and primary biliary cirrhosis are the most frequent although a clear common mechanism has never been proven. Overall, thyroid-related digestive manifestations were described decades ago but studies are still needed in order to confirm old concepts or elucidate undiscovered mechanisms. All practitioners must be aware of digestive symptoms due to dysthyroidism in order to avoid misdiagnosis of rare but potentially lethal situations.

Heme oxygenase-1 prevents hyperthyroidism induced hepatic damage via an antioxidant and antiapoptotic pathway

BACKGROUND

The exact pathogenesis of hepatic dysfunction in hyperthyroidism is still unknown. We aimed to investigate the pathogenesis of liver dysfunction caused by hyperthyroidism through inducing heme oxygenase-1 (HO-1) expression, which has antioxidant and anti-apoptotic properties.

METHODS

Rats were divided into six groups: untreated (group 1), treated with zinc protoporphyrin (ZnPP) (group 2), treated with hemin (group 3), treated with tri-iodothyronine (T3) (group 4), treated with T3 and ZnPP (group 5), and treated with T3 and hemin (group 6). After 22 d, oxidative stress and antioxidant enzymes and the expression of HO-1, mitochondrial permeability transition, cytochrome c, Bax, Bcl-2, caspase-3, caspase-8, and caspase-3 activity, and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay were examined.

RESULTS

Hyperthyroidism induced oxidative stress of liver tissue was ameliorated by HO-1 induction. Administration of hemin (HO-1 inducer) increased Bcl-2 expression. Decreased expression of cytochrome c was accompanied by a decrease in caspase-3, caspase-8, Bax expression, and caspase-3 activity. The apoptotic activity and oxidative damage were found to be increased by the administration of ZnPP (HO-1 inhibitor). Immunohistochemistry findings supported these results.

CONCLUSION

HO-1 induction plays a protective role in the pathogenesis of the liver dysfunction in hyperthyroidism. This effect is dependent on modulation of the antiapoptotic and antioxidative pathways by HO-1 expression.

Hyperthyroidism induces apoptosis in rat liver through activation of death receptor-mediated pathways

BACKGROUND/AIMS

The molecular basis of hepatic dysfunction in thyrotoxicosis is not fully understood. Here, we investigated the effect of altered thyroidal status on death receptor pathways including p75 neurotrophin receptor (p75NTR), a member of tumor necrosis factor (TNF) receptor superfamily, in rat liver.

METHODS

Hyperthyroidism was induced in Sprague-Dawley rats by daily injections of triiodothyronine in a dose of 12.5 microg/100 g body weight for 10 days.

RESULTS

Terminal deoxynucleotide-transferase-mediated dUTP nick end labeling assay and caspase-3 activation data confirmed apoptosis in hyperthyroid rat liver. We observed the elevated levels of death ligands, TNF-alpha, Fas ligand and their cognate receptors, TNF-receptor-1 and Fas, and 8-fold increase in caspase-8 activation in hyperthyroid rat liver (p<0.001). We demonstrated for the first time that hyperthyroidism elevates p75NTR levels and its ligands, pro-nerve growth factor and pro-brain-derived neurotrophic factor, in rat liver. Further we showed that most of the apoptotic cells in hyperthyroid liver express p75NTR. We also demonstrated that triiodothyronine administration to rats causes NF-kappaB activation, but persistent exposure (10 days) to triiodothyronine deactivates NF-kappaB leading to sustained c-Jun N-terminal kinase (JNK) activation.

CONCLUSIONS

This study showed that hyperthyroidism-induced apoptosis in rat liver involves the activation of death receptor-mediated pathways, including p75NTR.

Thyroid hormone inhibits biliary growth in bile duct-ligated rats by PLC/IP(3)/Ca(2+)-dependent downregulation of SRC/ERK1/2

The role of the thyroid hormone agonist 3,3',5 l-tri-iodothyronine (T3) on cholangiocytes is unknown. We evaluated the in vivo and in vitro effects of T3 on cholangiocyte proliferation of bile duct-ligated (BDL) rats. We assessed the expression of alpha(1)-, alpha(2)-, beta(1)-, and beta(2)-thyroid hormone receptors (THRs) by immunohistochemistry in liver sections from normal and BDL rats. BDL rats were treated with T3 (38.4 mug/day) or vehicle for 1 wk. We evaluated 1) biliary mass and apoptosis in liver sections and 2) proliferation in cholangiocytes. Serum-free T3 levels were measured by chemiluminescence. Purified BDL cholangiocytes were treated with 0.2% BSA or T3 (1 muM) in the absence/presence of U-73122 (PLC inhibitor) or BAPTA/AM (intracellular Ca(2+) chelator) before measurement of PCNA protein expression by immunoblots. The in vitro effects of T3 (1 muM) on 1) cAMP, IP(3), and Ca(2+) levels and 2) the phosphorylation of Src Tyr139 and Tyr530 (that, together, regulate Src activity) and ERK1/2 of BDL cholangiocytes were also evaluated. alpha(1)-, alpha(2)-, beta(1)-, and beta(2)-THRs were expressed by bile ducts of normal and BDL rats. In vivo, T3 decreased cholangiocyte proliferation of BDL rats. In vitro, T3 inhibition of PCNA protein expression was blocked by U-73122 and BAPTA/AM. Furthermore, T3 1) increased IP(3) and Ca(2+) levels and 2) decreased Src and ERK1/2 phosphorylation of BDL cholangiocytes. T3 inhibits cholangiocyte proliferation of BDL rats by PLC/IP(3)/Ca(2+)-dependent decreased phosphorylation of Src/ERK1/2. Activation of the intracellular signals triggered by T3 may modulate the excess of cholangiocyte proliferation in liver diseases.

Severe hyperthyroidism induces mitochondria-mediated apoptosis in rat liver

Thyrotoxicosis may be associated with a variety of abnormalities of liver function. The pathogenesis of hepatic dysfunction in thyrotoxicosis is unknown, but has been attributed to mitochondrial dysfunction. We studied the effect of altered thyroid function on the apoptotic index in rat liver. Extensive DNA fragmentation and significantly increased caspase-3 activity (P <.001) and caspase-9 activation (P <.005) were observed in hyperthyroid rat liver; cell death by apoptosis was confirmed. In hyperthyroid rat liver, 60% of mitochondria exhibited disruption of their outer membranes and a decrease in the number of cristae. These findings, along with significant translocation of cytochrome c and second mitochondria-derived activator of caspases to cytosol (P <.005), suggest activation of a mitochondrial-mediated pathway. However, no change in the expression levels of Bcl-2, Bax, and Bcl-x(L) were found in hyperthyroidism. For in vitro experiments, rat liver mitochondria were isolated and purified in sucrose density gradients and were treated with triiodothyronine (T3; 2-8 microM). T3 treatment resulted in an abrupt increase in mitochondrial permeability transition. Using a cell-free apoptosis system, the apoptogenic nature of proteins released from mitochondria was confirmed by observing changes in nuclear morphologic features and DNA fragmentation. Proteins released by 6 microM T3 contained significantly increased amounts of cytochrome c (P <.01) and induced apoptotic changes in 67% of nuclei. In conclusion, using in vivo and in vitro approaches, we provide evidence that excess T3 causes liver dysfunction by inducing apoptosis, as a result of activation of a mitochondria-dependent pathway. Thus, the results of this study provide an explanation for liver dysfunction associated with hyperthyroidism.