2508 A Case of Graves Disease Presenting With Severe Hepatic Dysfunction

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Conference Proceeding

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Publication Title

The American Journal of Gastroenterology



Cholestatic hepatitis attributed to thyroid disease is a rare presentation with only a handful cases reported in the literature. Often confused as a potential adverse effect of anti-thyroid therapy, this entity can prove to be elusive to diagnose and challenging to manage.


A 37-year old healthy male presented complaining of jaundice, pruritus, fatigue and significant weight loss over 3 months. His only medication was oxycodone for chronic back pain after a remote accident. Physical examination demonstrated scleral icterus with no hepatosplenomegaly or stigmata of chronic liver disease. Diagnostic evaluation demonstrated (1) Lymphocytic leukocytosis of 14,000 cells/mm3, microcytic anemia, normal platelet count, kidney function, serum albumin and INR, (2) mixed LFT pattern (R factor: 2.6) with marked cholestasis with ALP of 222 IU/L, AST of 132 IU/L, ALT of 192 IU/L, total bilirubin of 17.3 mg/dl with a direct fraction of 9.4 mg/dl (3) negative hepatitis, viral serologies, ANA, and AMA (4) elevated ferritin of 2,938 ng/ml with heterozygous H63D mutation, (5) normal MRCP (6) liver biopsy demonstrating cholestatic changes not compatible with autoimmune hepatitis, minimal iron deposition, and no evidence of fibrosis (7) TSH < 0.01, fT4 (free thyroxine) of 1.5, fT4 (free triiodothyronine) of 4.3 and strongly positive thyroid stimulating immunoglobulins, TSH receptor antibodies, and anti-TPO antibodies. A radioiodine uptake scan (RAI) was consistent with Grave's disease. The patient was started on methimazole, propranolol and underwent subsequent surgical thyroidectomy with complete resolution of his symptoms and near complete resolution of his hepatitis in 3 months duration.


Thyrotoxicosis presenting with severe hepatic dysfunction can prove a challenging entity to treat. Challenges include potential hepatotoxic effects of methimazole, propylthiouracil or radioactive iodine, and the risks of inducing thyroid storm by performing a surgical thyroidectomy without appropriate pre-treatment. The case reported highlights the importance of recognizing liver injury secondary to thyrotoxicosis, and reports successful treatment with surgical thyroidectomy after pre-treatment with methimazole and propanolol.



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American College of Gastroenterology Conference, San Antonio, TX, October 25-30, 2019.

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