J Med Cases

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

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website http://www.journalmc.org

Case Report

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

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

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. Thyroid color duplex ultrasonography showed enlarged thyroid and active blood flow indicating hyperthyroidism.

**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.
Hematology	Glu 121 mg/dL
WBC 7 700/µL	T-Chol 29 mg/dL
RBC 376 × 10⁴/µL	TG 49 mg/dL
Hb 11.8 g/dL	Na 138 mEq/L
Ht 33.7%	K 2.6 mEq/L
Plt 9.4 × 10⁴/µL	Cl 94 mEq/L
Coagulation and fibrinolysis tests	Ca 8.1 mg/dL
PT < 5.0%	NH3 30 µg/dL
APTT 82.9 sec	CRP 2.11 mg/dL
Fibrinogen 103.1 mg/dL	TBA 87.1 µmol/L
FDP < 2.5 µg/dL	ANA 1:40
AT-III 33.8%	AMA(M2) < 5 U/mL
Serum chemistry	IgG 2 600 mg/dL
TP 6.5 g/dL	HBsAg (-)
Alb 2.3 g/dL	HCVAb (-)
TBIL 27.5 mg/dL	EB VCA-G (+)
DBIL 24.8 mg/dL	EB VCA-M (-)
BUN 25.4 mg/dL	IgM-HBcAb (-)
Cr 1.09 mg/dL	EBNAIgG (+)
UA 5.1 mg/dL	CMV-IgG (+)
AST 49 U/L	CMV-IgM (-)
ALT 42 U/L	BNP 651 pg/mL
ALP 522 U/L	TSH < 0.003 µIU/mL
γ-GTP 25 U/L	FT3 15 pg/dL
Ch-E 48 U/L	FT4 4.73 ng/dL
LDH 283 U/L	TRAb 80.3%
CPK 67 U/L

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.

Hematology

Glu 121 mg/dL

WBC 7 700/µL

T-Chol 29 mg/dL

RBC 376 × 10⁴/µL

TG 49 mg/dL

Hb 11.8 g/dL

Na 138 mEq/L

Ht 33.7%

K 2.6 mEq/L

Plt 9.4 × 10⁴/µL

Cl 94 mEq/L

Coagulation and fibrinolysis tests

Ca 8.1 mg/dL

PT < 5.0%

NH3 30 µg/dL

APTT 82.9 sec

CRP 2.11 mg/dL

Fibrinogen 103.1 mg/dL

TBA 87.1 µmol/L

FDP < 2.5 µg/dL

ANA 1:40

AT-III 33.8%

AMA(M2) < 5 U/mL

Serum chemistry

IgG 2 600 mg/dL

TP 6.5 g/dL

HBsAg (-)

Alb 2.3 g/dL

HCVAb (-)

TBIL 27.5 mg/dL

EB VCA-G (+)

DBIL 24.8 mg/dL

EB VCA-M (-)

BUN 25.4 mg/dL

IgM-HBcAb (-)

Cr 1.09 mg/dL

EBNAIgG (+)

UA 5.1 mg/dL

CMV-IgG (+)

AST 49 U/L

CMV-IgM (-)

ALT 42 U/L

BNP 651 pg/mL

ALP 522 U/L

TSH < 0.003 µIU/mL

γ-GTP 25 U/L

FT3 15 pg/dL

Ch-E 48 U/L

FT4 4.73 ng/dL

LDH 283 U/L

TRAb 80.3%

CPK 67 U/L

**Table 2.** Characteristics of Similar Cases Reported in the Literature
First author	Age	Chief complaint	Complications	Trigger	Therapy	Pathology	Peak TBIL	Outcome
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]	39	Fatigue, sweating	-	-	Iodine, PTU, PSL	Cholestasis	35	Alive
Kobayashi [6]	69	Nausea, vomiting, diarrhea, anorexia	CHF, DIC, hypoglycemia	Cold	Thiamazole, Iodine	-	3.6	Alive
Kandil [7]	28	Nausea, vomiting, anorexia, abdominal discomfort	Fulminant hepatic failure, CHF, ARDS	Stop PTU due to liver dysfunction	Liver transplant, thyroidectomy	Necrosis (drug)	AST/ALT1600/2101	Alive
Regelmann [8]	17	Vomiting, diarrhea,dark-colored urine,jaundice	-	-	Methimazole	+	28	Alive
Thompson [9]	54	Malaise	-	Unknown	Carbimazole	-	14.35	Alive
Chong [10]	35	Acute delirium, fever, vomiting	Acute liver failure, acute kidney injury, lactic acidosis, DIC, heart failure, acute pulmonary edema	Absent anti-thyroid therapy	Antithyroid drug	-	1.8	Alive
Hull [11]	38	Nausea, vomit, fatigue, pruritus, diarrhea	-	Unknown	Propilthiouracil, near-total thyroidectomy	-	35.2	Alive
Hull [11]	35	Unconscious	Atrial fibrillation	Unknown	Near-total thyroidectomy	Diffuse hepatocellular ballooning, intrahepatic cholestasis, mild portal lymphocytic infiltration	42	Alive

Table 2. Characteristics of Similar Cases Reported in the Literature

First author

Age

Chief complaint

Complications

Trigger

Therapy

Pathology

Peak TBIL

Outcome

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]

Fatigue, sweating

Iodine, PTU, PSL

Cholestasis

Alive

Kobayashi [6]

Nausea, vomiting, diarrhea, anorexia

CHF, DIC, hypoglycemia

Cold

Thiamazole, Iodine

3.6

Alive

Kandil [7]

Nausea, vomiting, anorexia, abdominal discomfort

Fulminant hepatic failure, CHF, ARDS

Stop PTU due to liver dysfunction

Liver transplant, thyroidectomy

Necrosis (drug)

AST/ALT1600/2101

Alive

Regelmann [8]

Vomiting, diarrhea,dark-colored urine,jaundice

Methimazole

Alive

Thompson [9]

Malaise

Unknown

Carbimazole

14.35

Alive

Chong [10]

Acute delirium, fever, vomiting

Acute liver failure, acute kidney injury, lactic acidosis, DIC, heart failure, acute pulmonary edema

Absent anti-thyroid therapy

Antithyroid drug

1.8

Alive

Hull [11]

Nausea, vomit, fatigue, pruritus, diarrhea

Unknown

Propilthiouracil, near-total thyroidectomy

35.2

Alive

Hull [11]

Unconscious

Atrial fibrillation

Unknown

Near-total thyroidectomy

Diffuse hepatocellular ballooning, intrahepatic cholestasis, mild portal lymphocytic infiltration

Alive