Department of Hepatic Biliary Pancreatic Medicine, First Hospital of Jilin University, 71 Xinmin Avenue, Changchun, 130021, Jilin, China.
The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
BMC Gastroenterol. 2022 Feb 10;22(1):59. doi: 10.1186/s12876-022-02133-z.
Liver injury related to Graves' Disease (GD) includes hepatotoxicity of thyroid hormone excess, drug-induced liver injury, and changes resulting from concomitant liver disease. Methimazole (MMI) has been shown to induce several patterns of liver injury. However, the diagnosis and treatment of autoimmune hepatitis (AIH) overlapping with either GD or chronic hepatitis B are challenging.
A 35-year-old man from China presented with a two-year history of GD and a 10-day history of progressive jaundice. He had taken MMI for two months and discontinuing treatment due to liver toxicity 1 year ago and for another 6 days 20 days prior to hospitalization. The patient was diagnosed with GD overlapping with chronic hepatitis B and MMI-induced liver injury with early stage of acute-on-chronic liver failure on admission. However, the elevated aminotransferase and bilirubin levels could not be controlled after correction of liver failure and effective control of HBV replication and hyperthyroidism by daily oral entecavir and one-time oral administration of 131-iodine. The patient underwent liver biopsy on the 43rd day of hospitalization, showing HBsAg expression on the membrane of hepatocytes and typical histopathological characteristics of AIH. He was finally diagnosed with GD overlapping with chronic hepatitis B and MMI-induced liver injury and AIH. The elevated aminotransferase and bilirubin completely returned to normal by 3-month glucocorticoid therapy and continuous entecavir treatment and there was no recurrence during a 6-month follow-up, suggesting that AIH in this patient is different from classical AIH or GD-associated AIH.
GD together with AIH is a complex and difficult subject. It needs to be clarified whether MMI or HBV can act as a trigger for AIH in this patient.
与格雷夫斯病（GD）相关的肝损伤包括甲状腺激素过多引起的肝毒性、药物性肝损伤以及同时存在的肝病引起的变化。甲巯咪唑（MMI）已被证明可引起多种类型的肝损伤。然而，重叠有 GD 或慢性乙型肝炎的自身免疫性肝炎（AIH）的诊断和治疗具有挑战性。
一名 35 岁的中国男性，有两年 GD 病史和十天进行性黄疸史。一年前因肝毒性而开始服用 MMI 并停药，20 天前因另一种情况又开始服用 MMI，共服用了 6 天。入院时，该患者被诊断为重叠有慢性乙型肝炎的 GD 和 MMI 诱导的肝损伤，伴有急性肝衰竭失代偿期。然而，在纠正肝衰竭和通过每日口服恩替卡韦和一次性口服 131-碘有效控制 HBV 复制和甲状腺功能亢进后，升高的转氨酶和胆红素水平仍无法得到控制。患者在入院第 43 天行肝活检，显示肝细胞膜上 HBsAg 表达和 AIH 的典型组织病理学特征。最终诊断为重叠有慢性乙型肝炎的 GD、MMI 诱导的肝损伤和 AIH。通过 3 个月的糖皮质激素治疗和持续恩替卡韦治疗，升高的转氨酶和胆红素完全恢复正常，在 6 个月的随访中无复发，提示该患者的 AIH 不同于经典 AIH 或 GD 相关 AIH。
GD 合并 AIH 是一个复杂且困难的问题。需要明确在该患者中，MMI 还是 HBV 可作为 AIH 的触发因素。
