A case of hyperthyroidism presenting with cholestasis
Ahmed Helmy1 & Evon Boules1
An 85 year old lady was admitted with painless jaundice and cholestatic liver functions (LFTs). Investigations organised by gastroenterologists were fine including hepatitis viral screen, copper and ceruloplasmin levels, alpha -one antitrypsin, alpha -fetoprotein, immunoglobulins, auto-immune screen and ultrasound scan of the liver. In view of palpitations and weight loss, thyroid functions (TFTs) were done and showed biochemical hyperthyroidism: FT4 of 36.8 pmol/L (1222), FT3 of 9.1 pmol/L (3.16.8) and TSH <0.01 mU/L (0.34.2) with positive anti-thyroid peroxidase antibodies 225 IU/ml (0135), negative TSH receptor antibodies and multinodular goitre on ultrasound scan of thyroid. Clinically, the patient had just palpable small goitre with no thyrotoxic signs. Patient was referred to endocrine team and started on a week of potassium iodide(trying to avoid any potential hepatotoxic effect of carbimazole or propylthiuoracil). LFTs & TFTs started to improve gradually the following week when potassium iodide was replaced by carbimazole with further improvement of LFTs & TFTs. Although abnormalities in liver functions particularly raised serum alkaline phosphatase have been reported with thyrotoxicosis, yet cholestasis has been rare. Retrograde detailed drug history revealed co-amoxiclav therapy for a week six weeks prior to presentation. Although drug history might have a contributing factor to cholestasis, we remind endocrinologists to consider LFTs abnormalities associated with thyrotoxic patients.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.