Endocrine Abstracts

Background: Hyperthyroidism often presents with aberrant liver function. The differential diagnosis of this presentation includes thyrotoxicosis-associated liver dysfunction or antithyroid drug-induced liver dysfunction. We present a case where Propylthiouracil treatment resulted in acute liver failure.

Case Presentation: A female patient diagnosed with Grave’s disease in August 2023 initially received carbimazole but discontinued this due to vomiting. Subsequent initiation of PTU in September 2023 resulted in admission with decreased conscious level, jaundice and severe acute liver failure after six weeks of starting. Laboratory findings on admission included a bilirubin level of 384, INR of 10.9, ALT of 1200. Propylthiouracil was discontinued.

Intervention and Post-Transplant Course: Urgent liver transplantation was performed in early November 2023, with post-surgical Klebsiella hospital-acquired pneumonia, a prolonged stay in intensive care and a slow wean requiring a tracheostomy. Despite transplantation, she had persistent abnormal liver function. Liver USS and Doppler studies confirmed mild hepatic steatosis with patent vessels. Liver biopsies done at four weeks post-transplant and six weeks revealed severe steatosis and minimal portal inflammation, excluding rejection as a cause. The patient continued azathioprine, tacrolimus, and prednisolone (1 mg daily) for liver function and hyperthyroidism management.

Challenges in Thyroid Management: Efforts to manage hyperthyroidism post-transplant with carbimazole were met with vomiting, which was managed with a dose reduction. She is planned for elective thyroidectomy as of writing.

Importance and Rarity: This case underscores the challenges in navigating severe hepatotoxicity induced by PTU in Grave’s disease. Clinicians should be vigilant for this rare but severe complication of PTU treatment.

Conclusion: This distinctive case provides valuable insights into the intricacies of thyroid medication-associated liver failure. It highlights the importance of cautious PTU use, contributing to the growing body of evidence guiding clinicians in managing similar challenging clinical scenarios.

TSH remained !0.01 mIU/l after the 20th November

Keywords: Grave’s disease, propylthiouracil, hepatotoxicity, liver transplantation, caution. TSH remained <0.01mIU/l after the 20th November