Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 5, Number 5, May 2014, pages 273-278


A Case of Graves’ Disease Complicated With Thyroid Storm and Acute Hepatic Failure

Figures

Figure 1.
Figure 1. Abdominal ultrasonography showed dilated inferior vena cava and hepatic vein, liver margin was dull, right lobe was atrophic and intrahepatic bile ducts were not dilated.
Figure 2.
Figure 2. Thyroid color duplex ultrasonography showed enlarged thyroid and active blood flow indicating hyperthyroidism.
Figure 3.
Figure 3. Clinical course after admission.

Tables

Table 1. Laboratory Findings on Admission
 
WBC: white blood cells; RBC: red blood cells; Ht: hematocrit; Plt: platelet; PT: prothrombin time; APTT: activated partial thromboplastin time; FDP: fibrin-fibrinogen degradation products; AT-III: antithronbin-III; TP: total protein; Alb: albumin; TBIL: total bilirubin; DBIL: direct bilirubin; BUN: blood urea nitrogen; Cr: creatinine; UA: uric acid; AST: aspartate aminotransferase; ALT: alanine aminotaransferase; γ-GTP: gamma glutamyltranspeptidase; Ch-E: cholinesterase; LDH: lactate dehydrogenase; CPK: creatine phosphokinase; Glu: glucose; T-Chol: total cholesterol; TG: trigricelide; NH3: ammonia; CRP: C-reactive protein; TBA: total bile acid; ANA: anti-nuclear antibody; AMA: anti-mitochondrial M2 antibody; IgG: immunoglobulin G; HBsAg: hepatitis B surface antigen; HCVAb: hepatitis C virus antibody; EB VCA-G: Epstein-Barr virus capsid antibody IgG; EB VCA-M: EB virus capsid antibody IgM; IgM-HBcAb: hepatitis B core antibody IgM; EBNAIgG: EB virus determined nuclear antigen IgG; CMV-IgG: cytomegalovirus antigen IgG; BNP: brain natriuretic peptide; TSH: thyroid stimulating hormone; FT3: free triiodothyronine; FT4: free thyroxine; TRAb: thyrotropin receptor antibody.
HematologyGlu 121 mg/dL
  WBC 7 700/µLT-Chol 29 mg/dL
  RBC 376 × 104/µLTG 49 mg/dL
  Hb 11.8 g/dLNa 138 mEq/L
  Ht 33.7%K 2.6 mEq/L
  Plt 9.4 × 104/µLCl 94 mEq/L
Coagulation and fibrinolysis testsCa 8.1 mg/dL
  PT < 5.0%NH3 30 µg/dL
  APTT 82.9 secCRP 2.11 mg/dL
  Fibrinogen 103.1 mg/dLTBA 87.1 µmol/L
  FDP < 2.5 µg/dLANA 1:40
  AT-III 33.8%AMA(M2) < 5 U/mL
Serum chemistryIgG 2 600 mg/dL
  TP 6.5 g/dLHBsAg (-)
  Alb 2.3 g/dLHCVAb (-)
  TBIL 27.5 mg/dLEB VCA-G (+)
  DBIL 24.8 mg/dLEB VCA-M (-)
  BUN 25.4 mg/dLIgM-HBcAb (-)
  Cr 1.09 mg/dLEBNAIgG (+)
  UA 5.1 mg/dLCMV-IgG (+)
  AST 49 U/LCMV-IgM (-)
  ALT 42 U/LBNP 651 pg/mL
  ALP 522 U/LTSH < 0.003 µIU/mL
  γ-GTP 25 U/LFT3 15 pg/dL
  Ch-E 48 U/LFT4 4.73 ng/dL
  LDH 283 U/LTRAb 80.3%
  CPK 67 U/L

 

Table 2. Characteristics of Similar Cases Reported in the Literature
 
First authorAgeChief complaintComplicationsTriggerTherapyPathologyPeak TBILOutcome
CHF: congestive heart failure; DIC: disseminated intravascular coagulation; ARDS: acute respiratory distress syndrome; PTU: propylthiouracil; TBIL: total bilirubin; AST: aspartate aminotransferase; ALT: alanine aminotransferase.
Hasan [5]39Fatigue, sweating--Iodine, PTU, PSLCholestasis35Alive
Kobayashi [6]69Nausea, vomiting, diarrhea, anorexiaCHF, DIC, hypoglycemiaColdThiamazole, Iodine-3.6Alive
Kandil [7]28Nausea, vomiting, anorexia, abdominal discomfortFulminant hepatic failure, CHF, ARDSStop PTU due to liver dysfunctionLiver transplant, thyroidectomyNecrosis (drug)AST/ALT1600/2101Alive
Regelmann [8]17Vomiting, diarrhea,dark-colored urine,jaundice--Methimazole+28Alive
Thompson [9]54Malaise-UnknownCarbimazole-14.35Alive
Chong [10]35Acute delirium, fever, vomitingAcute liver failure, acute kidney injury, lactic acidosis, DIC, heart failure, acute pulmonary edemaAbsent anti-thyroid therapyAntithyroid drug-1.8Alive
Hull [11]38Nausea, vomit, fatigue, pruritus, diarrhea-UnknownPropilthiouracil, near-total thyroidectomy-35.2Alive
Hull [11]35UnconsciousAtrial fibrillationUnknownNear-total thyroidectomyDiffuse hepatocellular ballooning, intrahepatic cholestasis, mild portal lymphocytic infiltration42Alive