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Muacevic A, Adler JR, Suzuki K, Kakisaka K, Abe K. Over 3-Years Follow-Up of a Case of Primary Biliary Cholangitis With Autoimmune Hyperthyroidism: Factors Associated With Liver Dysfunction. Cureus 2022; 14:e32941. [PMID: 36712741 PMCID: PMC9873900 DOI: 10.7759/cureus.32941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2022] [Indexed: 12/27/2022] Open
Abstract
We present a rare case of a 50-year-old woman with simultaneous primary biliary cholangitis (PBC) and autoimmune hyperthyroidism in which the factors associated with liver dysfunction were evaluated over a 3-year follow-up period. Although serum thyroid hormone levels improved after the administration of thiamazole, thyroid dysfunction was not directly associated with liver dysfunction. During the follow-up period, anti-hyperlipidemic drug therapy and eradication therapy for Helicobacter pylori (HP) infection caused transient elevation of serum transaminase levels. It should be recognized that serum liver enzyme levels might be affected by various factors, including the therapies for the many complications of PBC.
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Lee YW, Lin YY, Weng SF, Hsu CH, Huang CL, Lin YP, Hsieh YS. Clinical significance of hepatic function in Graves disease with type 2 diabetic mellitus: A single-center retrospective cross-sectional study in Taiwan. Medicine (Baltimore) 2022; 101:e30092. [PMID: 36042671 PMCID: PMC9410657 DOI: 10.1097/md.0000000000030092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Graves disease (GD) and type 2 diabetes mellitus (T2DM) both impair liver function; we therefore explored the possibility of a relationship among diabetic control, thyroid function, and liver function. This retrospective, cross-sectional study compared serum liver function biomarkers of primary GD patients in a single center between 2016 and 2020, derived from clinical databases, and clarified the correlation of liver function in GD patients with or without T2DM. Furthermore, the diabetes mellitus group was divided into glycated hemoglobin A1C (HbA1C) <6.5% group and ≥6.5% group to further analyze the effect by disease control in patients. Statistical differences between groups were assessed using independent t tests to clarify the association of serum biomarkers between GD with T2DM. Pearson test was applied to assess within-group statistical correlation of serum biomarkers. The correlation of factors in each group was demonstrated by using the Kendall tau-b method and stepwise regression analysis. A total of 77 patients were included in the study. In the study population, glutamate pyruvate transaminase (GPT) was significantly correlated with thyroid-stimulating hormone, and HbA1C was significantly correlated with alkaline phosphatase (ALK-P), glutamate oxaloacetate transaminase (GOT), and GPT. An examination of GOT, GPT, free thyroxine (FT4), and HbA1C levels revealed a significant difference between the non-T2DM and T2DM groups. GPT also exhibited a significant correlation with triiodothyronine in the T2DM group. The T2DM group was further divided into groups: HbA1C <6.5% and ≥6.5%. The results demonstrated that ALK-P, GOT, GPT, and FT4 levels were significantly different between the groups. A significant correlation between ALK-P and thyroid-stimulating hormone and between GOT and FT4 was also identified in the HbA1C <6.5% group. Our single-center study revealed that diabetes affects liver function in patients with GD. For patients with T2DM, when liver function becomes impaired, thyroid function control deteriorates. GPT was correlated with triiodothyronine but not with FT4, which indicated the impairment of deiodination in the liver. This phenomenon was not observed in the non-T2DM population. The early detection of abnormal liver function in patients with GD and T2DM may help limit the development of comorbidities and improve disease management.
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Affiliation(s)
- Yi-Wei Lee
- Department of Internal Medicine, Taipei Medical University Hospital, Taiwan
| | - Yan-Yu Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taiwan
| | - Shuen-Fu Weng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
| | - Chung-Huei Hsu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
| | - Chen-Ling Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taiwan
| | - Yu-Pei Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taiwan
| | - Yu-Shan Hsieh
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taiwan
- *Correspondence: Yu-Shan Hsieh, School of Nursing, National Taipei University of Nursing and Health Sciences, Rm. S322, No. 365, Mingde Rd., Beitou Dist., Taipei City 112303, Taiwan (R.O.C.) (e-mail: )
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Yorke E. Hyperthyroidism and Liver Dysfunction: A Review of a Common Comorbidity. Clin Med Insights Endocrinol Diabetes 2022; 15:11795514221074672. [PMID: 35153522 PMCID: PMC8829710 DOI: 10.1177/11795514221074672] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/22/2021] [Indexed: 12/15/2022] Open
Abstract
Deranged liver enzymes due to hyperthyroidism rather than intrinsic liver pathology are not uncommon. The reported prevalence of liver biochemical abnormalities in patients with untreated thyrotoxicosis varies widely ranging from 15% to 76%. The suggested causes of liver dysfunction include direct hepatocyte injury, co-morbid heart failure, associated autoimmune conditions (especially in the setting of Graves' Disease), preexisting liver disease and drugs including antithyroid medications. Although, some patients may have a pattern of mild liver injury, about 1% to 2% can have fulminant hepatitis. Liver enzymes can return to normalcy in as many as 77% to 83% of patients once the initiations of thionamides are started in a timely fashion, which can help forestall complications and prevent or minimize multi-organ dysfunction. Clinicians should maintain a high index of suspicion for underlying hyperthyroidism in patients presenting with unexplained liver dysfunction or unexplained jaundice.
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Affiliation(s)
- Ernest Yorke
- Department of Medicine & Therapeutics, University of Ghana Medical School, Accra, Ghana
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Lavruk KZ, Dudiy PF, Skrypnyk NV, Mishchuk VH, Vytvytskiy ZY. Clinical-laboratory and ultrasound parallels of changes in the liver and thyroid gland in diffuse toxic goiter. J Med Life 2022; 15:78-88. [PMID: 35186140 PMCID: PMC8852630 DOI: 10.25122/jml-2021-0291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/30/2021] [Indexed: 11/05/2022] Open
Abstract
Detection of liver dysfunction in patients with diffuse toxic goiter (DTG) at an early stage allows for correcting it in time with appropriate therapy; therefore, diagnosing hepatobiliary system lesions in these patients is an important medical issue. We examined 62 patients, divided into two groups depending on the duration of the disease. The first group included patients with a disease duration of up to two years, the second group - patients with a disease duration of more than two years. The study and comparison of laboratory and multiparametric ultrasound criteria of liver and thyroid dysfunction were performed. Analysis of ultrasound signs of hepatobiliary system lesions in patients in the two groups showed that they were more common in the second group. There is a correlation between the stiffness of the parenchyma of the thyroid gland and liver and the duration of the disease, the level of free thyroxine (T4f), and antibodies to thyroid-stimulating hormone receptors (ArTTG). Increased liver stiffness was more common in patients with ArTTG levels above 20 IU/ml, and the degree of F1 fibrosis was higher at T4f greater than 50 pmol/l. To assess the condition of a patient with DTG and the need to correct treatment tactics, it is advisable to use the criteria of multiparametric ultrasound examination of the hepatobiliary system and thyroid gland.
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Affiliation(s)
- Khrystyna Zynoviivna Lavruk
- Department of Radiology and Radiation Medicine, Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine,Corresponding Author: Khrystyna Zynoviivna Lavruk, Department of Radiology and Radiation Medicine of Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine. E-mail:
| | - Petro Fedorovych Dudiy
- Department of Radiology and Radiation Medicine, Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine
| | | | - Vasyl Hryhorovych Mishchuk
- Department of General Practice (Family Medicine), Physical Rehabilitation and Sports Medicine, Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine
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Wafa B, Faten H, Mouna E, Fatma M, Mohamed A. Hyperthyroidism and hepatic dysfunction: Report of 17 cases. JGH Open 2020; 4:876-879. [PMID: 33102758 PMCID: PMC7578311 DOI: 10.1002/jgh3.12337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 03/17/2020] [Accepted: 03/24/2020] [Indexed: 11/08/2022]
Abstract
Aims Hyperthyroidism has been known to be associated with abnormalities of serum liver chemistry. The objective of our study is to describe clinical, biochemical and therapeutic features of hepatic dysfunction in hyperthyroidism. Methods and Results This retrospective study was conducted on patients hospitalized in our endocrinology department over 20 years. We included patients with untreated and noniatrogenic hyperthyroidism among whom biochemical findings noted hepatic dysfunction and excluded those with concomitant liver disease. Our population is composed of 10 men and 7 women. The average age was 41.4 years. The mean serum level of free thyroxine was 83.8 pmol/L. The serum thyrotropin level was below the detection limit in 10/17 cases. Graves' disease was the most frequently found etiology of hyperthyroidism. Fourteen patients had hyperthyroidism's complications. Eleven patients manifested congestive heart failure. Hepatic dysfunction was moderate and severe in eight and two cases, respectively. Fifteen patients had cholestasis, associated with jaundice in five cases. Hepatocellular injury and synthetic liver dysfunction were noted in seven and five cases, respectively. Thyroid peroxidase antibodies were positively correlated with the serum level of bilirubin (ρ = 0.695; P = 0.038). A negative correlation was noted between alanine aminotransferase and left ventricular ejection fraction (ρ = −0.812; P = 0.05). Radioactive iodine was indicated in 15/17 cases. Follow‐up liver tests were performed in 11 cases. They all had normalized hepatic function once euthyroidism restored. Conclusion Liver injury in hyperthyroidism is relatively common, ranging from mild to severe. Therefore, patients presenting unexplained hepatic abnormalities require close examination and an evaluation of the thyroid function should be sought.
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Affiliation(s)
- Benothman Wafa
- Department of Endocrinology Hedi Chaker Hospital Sfax Tunisia
| | - Hadjkacem Faten
- Department of Endocrinology Hedi Chaker Hospital Sfax Tunisia
| | - Elleuch Mouna
- Department of Endocrinology Hedi Chaker Hospital Sfax Tunisia
| | - Mnif Fatma
- Department of Endocrinology Hedi Chaker Hospital Sfax Tunisia
| | - Abid Mohamed
- Department of Endocrinology Hedi Chaker Hospital Sfax Tunisia
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Yeliosof O, Marshall I. Severe hyperthyroidism without symptoms due to nonthyroidal illness in a child with acute hepatitis: case report and literature review. Ann N Y Acad Sci 2020; 1487:5-11. [PMID: 32965700 DOI: 10.1111/nyas.14493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/10/2020] [Accepted: 08/22/2020] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Olga Yeliosof
- Division of Pediatric Endocrinology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Ian Marshall
- Division of Pediatric Endocrinology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Yang Q, Liu W, Sun D, Wang C, Li Y, Bi X, Gu P, Feng H, Wu F, Hou L, Hou C, Li Y. 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. JOURNAL OF ETHNOPHARMACOLOGY 2020; 252:112602. [PMID: 32004632 DOI: 10.1016/j.jep.2020.112602] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/01/2019] [Accepted: 01/18/2020] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Qin Yang
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Wenqin Liu
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Dongmei Sun
- Guangdong Yifang Pharmaceutical Co., Ltd, Foshan, 528244, China
| | - Chunxia Wang
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yangxue Li
- Analysis Department of Chinese Medicine, Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine, Guangzhou, 510095, China
| | - Xiaoli Bi
- Analysis Department of Chinese Medicine, Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine, Guangzhou, 510095, China
| | - Peng Gu
- Institute of Comparative Medicine & Laboratory Animal Center, Southern Medical University, Guangzhou, China
| | - Haixing Feng
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Fuling Wu
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Lianbing Hou
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China; Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, 510515, China.
| | - Chuqi Hou
- School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, 510515, China.
| | - Yuhao Li
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China; Endocrinology and Metabolism Group, Sydney Institute of Health Sciences/Sydney Institute of Traditional Chinese Medicine, Sydney, NSW, 2000, Australia
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Zeng B, Yuan L, Chu J, Yang Y, Lin S. Challenges in early identification of causes and treatment of cholestasis in patients with hyperthyroidism: a case report and literature review. J Int Med Res 2019; 48:300060519891018. [PMID: 31840543 PMCID: PMC7604993 DOI: 10.1177/0300060519891018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Early identification of the causes of cholestasis is important for appropriate
management of patients with hyperthyroidism. We report a patient who had
hyperthyroidism and severe cholestasis after methimazole (MMI) treatment. The
patient was diagnosed as having MMI-induced cholestatic hepatitis. Treatment
with MMI was stopped at admission to hospital. However, his serum total
bilirubin (TBil) level rose from 410.5 µmol/L to 519.9 µmol/L and prothrombin
time activity (PTA) dropped from 81.0% to 52.2% in 10 days. To prevent further
deterioration of his liver function, plasma exchange was performed three times,
and dexamethasone (10 mg, intravenously) was used each time. His PTA rose to
101% and his TBil continued to increase to 669.8 µmol/L after plasma exchange.
He was subsequently diagnosed as having thyrotoxicosis-induced cholestasis and
treated with radioactive iodine (380 MBq) 2 weeks after admission. His
hyperthyroidism was significantly relieved, but the TBil level further increased
to 776.8 µmol/L. Three weeks after admission, oral prednisone (30 mg/day) was
used in this patient. Subsequently, his TBil levels gradually decreased and his
liver function almost normalized within 3 months. We discuss the literature on
cholestasis in the context of hyperthyroidism.
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Affiliation(s)
- Baimei Zeng
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Ling Yuan
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Jun Chu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Yanqing Yang
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Shide Lin
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
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Peripheral blood picture and aminotransferase activity in children with newly diagnosed Graves' disease at baseline and after the initiation of antithyroid drug therapy. Cent Eur J Immunol 2019; 44:132-137. [PMID: 31530982 PMCID: PMC6745550 DOI: 10.5114/ceji.2019.87063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/17/2019] [Indexed: 11/17/2022] Open
Abstract
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.
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Ba JH, Wu BQ, Wang YH, Shi YF. Therapeutic plasma exchange and continuous renal replacement therapy for severe hyperthyroidism and multi-organ failure: A case report. World J Clin Cases 2019; 7:500-507. [PMID: 30842962 PMCID: PMC6397818 DOI: 10.12998/wjcc.v7.i4.500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/21/2018] [Accepted: 12/30/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Severe hyperthyroidism is a life-threatening exacerbation of thyrotoxicosis, characterized by high fever and multiorgan failure. The most common medical treatments are administration of antithyroid drugs and radioactive iodine, and thyroidectomy. In some patients, antithyroid therapy is limited due to serious adverse effects or failure to control disease progression. In some extreme cases, such as thyroid storm, conventional therapy alone does not yield effective and rapid improvement before the development of multiorgan failure.
CASE SUMMARY This report describes a Chinese patient with severe hyperthyroidism accompanied by multiorgan failure, who was transferred to the medical intensive care unit of our hospital. The patient presented with palpitations, vomiting, diarrhea, and shortness of breath for a week. Laboratory tests showed elevation of thyroid hormones. Hepatic failure occurred with high aminotransferase levels and jaundice. Given her abnormal liver function and medication history, we could not exclude diagnosis of propylthiouracil-induced hepatic failure. Moreover, she also suffered from heart failure. Therapeutic plasma exchange (commonly known as TPE) and continuous renal replacement therapy (commonly known as CRRT) were used as life-saving therapy, which resulted in notable improvement of clinical symptoms and laboratory tests.
CONCLUSION Combined TPE and CRRT are safe and effective for patients with hyperthyroidism and multiorgan failure.
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Affiliation(s)
- Jun-Hui Ba
- Department of Medical Intensive Unit, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Ben-Quan Wu
- Department of Medical Intensive Unit, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Yan-Hong Wang
- Department of Medical Intensive Unit, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Yun-Feng Shi
- Department of Medical Intensive Unit, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
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11
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Carpenter RM, Wongward J. Graves’ disease presenting as severe postpartum pruritus. BMJ Case Rep 2018; 2018:bcr-2018-225347. [DOI: 10.1136/bcr-2018-225347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Lin TY, Shekar AO, Li N, Yeh MW, Saab S, Wilson M, Leung AM. Incidence of abnormal liver biochemical tests in hyperthyroidism. Clin Endocrinol (Oxf) 2017; 86:755-759. [PMID: 28199740 PMCID: PMC5386790 DOI: 10.1111/cen.13312] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/17/2017] [Accepted: 02/09/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Abnormal serum liver function tests are common in patients with untreated thyrotoxicosis, even prior to the initiation of antithyroidal medications that may worsen the severity of the abnormal serum liver biochemistries. There is a wide range of the incidence of these abnormalities in the published literature. The aim of this study was to assess the risks factors and threshold of thyrotoxicosis severity for developing an abnormal liver biochemical test upon the diagnosis of new thyrotoxicosis. DESIGN Single-institution retrospective cohort study. PATIENTS Patients of ≥18 years old receiving medical care at a large, academic, urban US medical centre between 2002-2016. MEASUREMENTS Inclusion criteria were a serum thyroid stimulating hormone (TSH) concentration of <0·3 mIU/l or ICD-9 code for thyrotoxicosis, with thyrotoxicosis confirmed by either a concurrent elevated serum triiodothyronine (T3) or thyroxine (T4) concentration ([total or free] within 3 months), and an available liver biochemical test(s) within 6 months of thyrotoxicosis. The biochemical liver tests assessed were serum aspartate transaminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (AP), gamma-glutamyltransferase (GGT), total bilirubin, and conjugated bilirubin concentrations. RESULTS In this cohort of 1514 subjects, the overall incidence of any biochemical liver test abnormality within 6 months of thyrotoxicosis was 39%. An initial serum TSH concentration <0·02 mIU/l, male gender, and African-American race were significant predictors of an abnormal serum liver biochemical test within 6 months of the diagnosis of new-onset untreated thyrotoxicosis. CONCLUSIONS This study identifies risk factors for patients who develop an abnormal serum liver biochemical test result within 6 months of a diagnosis of untreated thyrotoxicosis.
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Affiliation(s)
| | | | - Ning Li
- Department of Biomathematics, UCLA David Geffen School of Medicine
| | - Michael W. Yeh
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine
| | - Sammy Saab
- Division of Gastroenterology, Department of Medicine, UCLA David Geffen School of Medicine
| | | | - Angela M. Leung
- Division of Endocrinology, Diabetes, and Hypertension; Department of Medicine, UCLA David Geffen School of Medicine
- Division of Endocrinology, VA Greater Los Angeles Healthcare System
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Wang R, Tan J, Zhang G, Zheng W, Li C. Risk factors of hepatic dysfunction in patients with Graves' hyperthyroidism and the efficacy of 131iodine treatment. Medicine (Baltimore) 2017; 96:e6035. [PMID: 28151911 PMCID: PMC5293474 DOI: 10.1097/md.0000000000006035] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Fatima S, Puri R, Patnaik S, Mora J. When A Toxic Thyroid Makes The Liver Toxic: A Case Of Thyroid Storm Complicated By Acute Liver Failure. AACE Clin Case Rep 2017. [DOI: 10.4158/ep161496.cr] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Soleimanpour SA. Fulminant liver failure associated with delayed identification of thyroid storm due to heterophile antibodies. Clin Diabetes Endocrinol 2015; 1. [PMID: 26491542 PMCID: PMC4610393 DOI: 10.1186/s40842-015-0012-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Hepatic dysfunction during hyperthyroidism frequently occurs with mild abnormalities in liver function tests that are self-limited, improving after treatment of thyroid disease. With the exception of congestive heart failure or secondary hepatic disease, significant hepatic compromise during thyrotoxicosis is rare and often of unexplained origin. This report identifies a novel case of severe hepatic compromise in the setting of thyrotoxicosis that was not initially identified due to a falsely elevated TSH. A 43-year-old African-American man presented to the intensive care unit with severe jaundice, weight loss, thyroid bruit and altered mental status. Initial diagnosis of hyperthyroidism was delayed due to a non-suppressed TSH of 0.20 μU/mL. Laboratory studies identified dramatic hepatic synthetic dysfunction and elevated transaminases with a total bilirubin of 47.4 mg/dL, AST 259 U/L, and ALT 142 U/L. No toxins, structural or viral causes of liver disease were identified and the patient was prepared for potential liver biopsy. Heterophile antibodies were identified and removed by precipitation, demonstrating an undetectable TSH and free thyroxine 9.0 ng/dL consistent with hyperthyroidism. Subsequent treatment with thionamides, corticosteroids, and potassium iodide improved both thyroid and liver function and avoided unnecessary invasive testing. Heterophile antibodies remain as important interfering factors in TSH immunoassays, and thus, this case demonstrates the importance of matching the clinical picture with available laboratory data. In the absence of a known cause of hepatic dysfunction, hyperthyroidism should be considered as a potential etiology of acute liver failure of unknown origin.
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Affiliation(s)
- Scott A Soleimanpour
- Division of Metabolism, Endocrinology & Diabetes and Department of Internal Medicine of the University of Michigan Medical School, 1000 Wall Street, Brehm Tower Suite 5317, Ann Arbor, MI 48105, USA
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Zhang R, Tian X, Qin L, Wei X, Wang J, Shen J. Factors predicting abnormal liver function tests induced by Graves' disease alone: a retrospective cohort study. Medicine (Baltimore) 2015; 94:e839. [PMID: 25984670 PMCID: PMC4602566 DOI: 10.1097/md.0000000000000839] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Ruiguo Zhang
- From the Department of Nuclear Medicine, Tianjin First Central Hospital (RGZ, LQ, JQW, JS); Department of Pathology, Research Institute of Liver Diseases, Tianjin Second People's Hospital, Tianjin (XT); and Department of Radiology, The Sixth Affiliated People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China (XEW)
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50-jährige Patientin mit Ödemen und Blutungsneigung bei Schilddrüsenhormonexzess. Internist (Berl) 2014; 55:1352-5. [DOI: 10.1007/s00108-014-3542-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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