Sawhney Rahul, Dhingra Sadhna, Sood Gagan K
Internal Medicine, Baylor University Medical Center, Dallas, USA.
Anatomic Pathology, Baylor College of Medicine, Houston, USA.
Cureus. 2019 May 4;11(5):e4598. doi: 10.7759/cureus.4598.
A 24-year-old Hispanic woman presented to our facility with a two-week history of abdominal pain, nausea, vomiting, diarrhea, jaundice, and scleral icterus. Initial laboratory workup revealed elevated transaminases, direct hyperbilirubinemia, and positive anti-smooth muscle antibody. Liver biopsy confirmed the diagnosis of autoimmune hepatitis and our patient was started on oral prednisone therapy. Her liver enzymes initially began to normalize but then spontaneously started up-trending. She was subsequently readmitted to the hospital for further management, at which time she also complained of palpitations, heat intolerance, and sweating. Laboratory workup revealed hyperthyroidism secondary to Grave's disease. Our patient was not a candidate for methimazole or propylthiouracil treatment due to her hepatic dysfunction, so she was started on hydrocortisone due to its secondary effect of decreased conversion of thyroxine to triiodothyronine. She achieved biochemical remission of her autoimmune hepatitis on this regimen and was transitioned back to oral prednisone therapy. Her liver enzymes normalized once she underwent radioactive iodine ablation of her thyroid. This clinical course suggests that autoimmune hepatitis with concurrent Grave's disease may be refractory to treatment until the underlying hyperthyroid state is corrected.
一名24岁的西班牙裔女性因腹痛、恶心、呕吐、腹泻、黄疸和巩膜黄染两周前来我院就诊。初步实验室检查显示转氨酶升高、直接胆红素血症以及抗平滑肌抗体阳性。肝活检确诊为自身免疫性肝炎，患者开始接受口服泼尼松治疗。她的肝酶最初开始恢复正常，但随后又自发上升。随后她再次入院接受进一步治疗，此时她还抱怨有心悸、不耐热和出汗症状。实验室检查显示为格雷夫斯病继发的甲状腺功能亢进。由于肝功能不全，该患者不适合使用甲巯咪唑或丙硫氧嘧啶治疗，因此因其具有减少甲状腺素转化为三碘甲状腺原氨酸的继发作用，开始使用氢化可的松治疗。在此治疗方案下，她的自身免疫性肝炎实现了生化缓解，并转回口服泼尼松治疗。她在接受甲状腺放射性碘消融术后，肝酶恢复正常。这一临床过程表明，在潜在的甲状腺功能亢进状态得到纠正之前，并发格雷夫斯病的自身免疫性肝炎可能对治疗无效。
