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2015 ; 1
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Fulminant liver failure associated with delayed identification of thyroid storm
due to heterophile antibodies
#MMPMID26491542
Soleimanpour SA
Clin Diabetes Endocrinol
2015[Oct]; 1
(ä): ä PMID26491542
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Hepatic dysfunction during hyperthyroidism frequently occurs with mild
abnormalities in liver function tests that are self-limited, improving after
treatment of thyroid disease. With the exception of congestive heart failure or
secondary hepatic disease, significant hepatic compromise during thyrotoxicosis
is rare and often of unexplained origin. This report identifies a novel case of
severe hepatic compromise in the setting of thyrotoxicosis that was not initially
identified due to a falsely elevated TSH. A 43-year-old African-American man
presented to the intensive care unit with severe jaundice, weight loss, thyroid
bruit and altered mental status. Initial diagnosis of hyperthyroidism was delayed
due to a non-suppressed TSH of 0.20 ?U/mL. Laboratory studies identified dramatic
hepatic synthetic dysfunction and elevated transaminases with a total bilirubin
of 47.4 mg/dL, AST 259 U/L, and ALT 142 U/L. No toxins, structural or viral
causes of liver disease were identified and the patient was prepared for
potential liver biopsy. Heterophile antibodies were identified and removed by
precipitation, demonstrating an undetectable TSH and free thyroxine 9.0 ng/dL
consistent with hyperthyroidism. Subsequent treatment with thionamides,
corticosteroids, and potassium iodide improved both thyroid and liver function
and avoided unnecessary invasive testing. Heterophile antibodies remain as
important interfering factors in TSH immunoassays, and thus, this case
demonstrates the importance of matching the clinical picture with available
laboratory data. In the absence of a known cause of hepatic dysfunction,
hyperthyroidism should be considered as a potential etiology of acute liver
failure of unknown origin.