Successful management of patients with co-existent autoimmune hepatitis and graves' disease.
Rana S, Bhan A, and Salgia R. Successful management of patients with co-existent autoimmune hepatitis and graves' disease. Endocrine Reviews 2017; 38(3).
Introduction Graves' disease is an autoimmune disorder characterized by autoantibodies against the TSH receptor. Hyperthyroidism from Graves' disease is a high turnover state which can result in elevated liver enzymes. Autoimmune hepatitis (AIH) is a chronic liver disease that presents with elevated liver enzymes, gammaglobulinemia, and unique histological features. Here, we report 4 cases of women diagnosed with AIH and Graves' disease. Clinical cases Case 1 A 15 year old female was diagnosed with Graves' disease after workup revealed low TSH, elevated thyroid hormones, and elevated TSI. At baseline, she had elevated liver enzymes attributed to hyperthyroidism. She underwent RAI ablation. Due to persistently elevated liver enzymes, liver biopsy was performed revealing portal fibrosis and interface hepatitis consistent with AIH. Steroid therapy was initiated and she responded well. Case 2 An 11 year old female was diagnosed with Graves' disease after lab tests revealed low TSH with elevated T3 and T4. She failed anti-thyroid drug treatment and was eventually treated with RAI. Five years later, she developed AIH. This progressed despite treatment, and she underwent a successful liver transplant. Case 3 A 39 year old female presented to the hospital with malaise. She was diagnosed with Graves' disease and AIH. She was started on prednisone and anti-thyroid drugs. Subsequently, she was treated with RAI and she went into remission with AIH as well. She had a recurrence of the latter and required a liver transplant. Case 4 A 47 year old female presented with jaundice. Workup revealed elevated liver enzymes with positive ANA and ASMA. Liver biopsy revealed hepatic necrosis and bridging fibrosis confirming AIH. Immunosuppression was initiated with good response. She was later diagnosed with Graves' and was started on anti-thyroid drug therapy. She was maintained on long term methimazole and prednisone. Discussion As elevated liver enzymes are commonly seen in patients with Graves' disease, a high index of suspicion is required to diagnose concomitant AIH since Graves' disease is rarely associated with AIH. We described 4 patients with concomitant thyroid and liver disease. In some cases, the diagnosis of AIH was delayed as the initial liver enzyme abnormalities were attributed to hyperthyroidism. Physicians may be hesitant to use anti-thyroid drugs given their hepatic side effect profile. However, anti-thyroid drug therapy can be safely used even in the presence of advanced liver disease, and may prove beneficial. In 2 of our patients, liver enzymes improved after hyperthyroidism resolved. In patients with co-existent AIH and Graves' disease, RAI ablation is the preferred modality for treatment. AIH treated with immunosuppression may also treat Graves' disease with improvement of both liver and thyroid function.