Difficult management of a thyrotoxic patient with abnormal liver function tests
Shabeeha Memon, Robin Polson & Hisham Maksoud
Thyrotoxicosis is associated with abnormal liver function test through a poorly understood mechanism.
We report a case of a 67 years old lady presenting with retrosternal chest pain and weight loss. Examination was unremarkable other than marked spider naevi. The Liver function tests showed raised ALT, GGT and Alkaline Phosphatase. She had profoundly deranged thyroid function tests with raised T3 and T4 with highly suppressed TSH.
Hepatic ultrasound showed an irregular mass. A CT scan of Chest and Abdomen showed Liver malignancy (primary or secondary) with lung metastasis and retrocrural lymphadenopathy. A CT guided biopsy confirming Hepatocellular carcinoma.
She was referred to Oncology for further input and started on treatment with carbimazole.
This ladys liver mass could easily have been overlooked if weight loss was attributed solely to thyrotoxicosis, causing a delay in diagnosis.Treatment for this lady is far more complicated than it appears. She was admitted with neutropenic sepsis secondary to carbimazole even before chemotherapy was commenced, which complicated the management further.
She is not a candidate for Radio- iodine to avoid exposure to healthcare workers in the post radiation phase or surgery because of the progression of the tumour and thyrotoxic state.
She was treated with steroids and a limited course of Lugols iodine until her white cell count recovered sufficiently to allow introduction of Propylthiouracil.
This case illustrates the importance of carbimazole-induced neutropenia and the need to be vigilant in the management of altered liver function tests with thyrotoxicosis.