Introduction: Hepatic dysfunction in hyperthyroidism may occur due to high thyroid hormones, medications or associated autoimmune liver disease. Autoimmune hepatitis or primary biliary cirrhosis (PBC) has rarely been reported in Graves disease. We report a patient presenting with pruritus and diagnosed as accompanying PBC and Graves disease.
Case: A 50 years old female patient applied with progressive pruritus for at least 4 months. Laboratory investigations showed normal alanine aminotransferase and aspartate aminotransferase. Serum alkaline phosphatase (ALP) was 125 IU/l (≤105 IU/l), gamma glutamyl transferase (GGT) was 132 IU/l (≤42), and total serum bilirubin and conjugated bilirubin were within normal ranges. She had low TSH (<0.005 U/l) and high serum free T4 (4.6 ng/dl) and free T3 (14.71 pg/ml). Thyroid peroxidase antibody and thyroid stimulating hormone receptor antibody were also positive. She was afebrile and had regular pulse rate of 110/min and normal blood pressure. There was no exophthalmus, goiter, hepatomegaly or splenomegaly in physical examination. Ultrasonographically, the thyroid gland was enlarged with increased vascularity. Technetium-99m scintigraphy showed increased activity throughout the gland with cold nodules in an enlarged thyroid gland. She was started on methimazole and propranolol. After a week of treatment, her ALP and GGT levels raised to 160 and 151, respectively that we discontinued methimazol. Serology tests for viral hepatitis, human immunodeficiency virus and cytomegalovirus were negative; laboratory tests excluded copper, iron-related metabolic disorders and autoimmune liver diseases. Anti-mitochondrial antibody was found positive and PBC was diagnosed with clinical and laboratory findings. She was started on ursodeoxycholic acid and underwent bilateral total thyroidectomy.
Conclusion: PBC is often associated with other autoimmune diseases. When a cholestatic pattern of liver enzymes is observed during follow-up for Graves disease, PBC should be considered in the differential diagnosis.
20 - 23 May 2017
European Society of Endocrinology