A Case of Autoimmune Hepatitis Combined with Graves' Disease

Jong Hyun Jhee; Hyun Ju Kim; Wonseok Kang; Sewha Kim; Do Young Kim

doi:10.4166/kjg.2015.65.1.48

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Jhee, Kim, Kang, Kim, and Kim: A Case of Autoimmune Hepatitis Combined with Graves' Disease

Case Report

Korean J Gastroenterol 2015;65(1):48-51.

Published online: 4 October 2015

DOI: https://doi.org/10.4166/kjg.2015.65.1.48

A Case of Autoimmune Hepatitis Combined with Graves' Disease

Jong Hyun Jhee¹, Hyun Ju Kim¹, Wonseok Kang¹, Sewha Kim², Do Young Kim^1,³

¹Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea

²Department of Pathology, Yonsei University College of Medicine, Seoul, Korea

³Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea

Correspondence to: Do Young Kim, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun- gu, Seoul 120-752, Korea. Tel: +82-2-2228-1992, Fax: +82-2-393-6884, E-mail: DYK1025@yuhs.ac

Received 20 June 201412 July 2014 Accepted 13 July 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

A 25-year-old woman presented with jaundice, palpitation, and weight loss of 5 kg during a period of 2 weeks. Laboratory tests showed elevated levels of liver enzymes (AST 1,282 IU/L, ALT 1,119 IU/L) and total bilirubin (6.4 mg/dL); negative for hepatitis virus infection; elevated serum levels of triiodothyronine (T3, 3.60 ng/dL), free thyroxine (fT4, 3.82 ng/dL), and lowered serum level of thyroid stimulating hormone (TSH, <0.025 μIU/mL); and positive for thyroid stimulating antibody and anti-mitochondrial antibody (AMA). The liver biopsy findings were consistent with autoimmune hepatitis (AIH). Accordingly, oral steroid therapy was started with 60 mg of prednisolone under the impression of AIH associated with Graves' disease. After a week of steroid therapy, the clinical manifestation showed significant improvement, with normalization of both liver and thyroid functions. Diagnosis of the liver condition of patients who present with hyperthyroidism and liver dysfunction is important, so that appropriate therapy can be promptly initiated.

Keywords: Autoimmune hepatitis, Graves disease, Steroid

References

1. Krawitt EL. Autoimmune hepatitis. N Engl J Med. 2006; 354:54–66.

2. Liberal R, Grant CR, Longhi MS, Mieli-Vergani G, Vergani D. Diagnostic criteria of autoimmune hepatitis. Autoimmun Rev. 2014; 13:435–440.

3. Reich DJ, Fiel I, Guarrera JV, et al. Liver transplantation for autoimmune hepatitis. Hepatology. 2000; 32:693–700.

4. Lim KN, Casanova RL, Boyer TD, Bruno CJ. Autoimmune hepatitis in African Americans: presenting features and response to therapy. Am J Gastroenterol. 2001; 96:3390–3394.

5. Czaja AJ, Freese DK. American Association for the Study of Liver Disease. Diagnosis and treatment of autoimmune hepatitis. Hepatology. 2002; 36:479–497.

6. Krawitt EL, Bonis PAL. Treatment of autoimmune hepatitis. Rose BD, editor. UpToDate, version 13.1. Wellesley: UpToDate;2005.

7. Alvarez F, Berg PA, Bianchi FB, et al. International Autoimmune Hepatitis Group Report: review of criteria for diagnosis of autoimmune hepatitis. J Hepatol. 1999; 31:929–938.

8. Johnson PJ, McFarlane IG. Meeting report: International Autoimmune Hepatitis Group. Hepatology. 1993; 18:998–1005.

9. Abe M, Hiasa Y, Masumoto T, et al. Clinical characteristics of autoimmune hepatitis with histological features of acute hepatitis. Hepatol Res. 2001; 21:213–219.

10. Cui B, Abe M, Hidata S, et al. Autoimmune hepatitis associated with Graves' disease. Intern Med. 2003; 42:331–335.

11. Gough A, Chapman S, Wagstaff K, Emery P, Elias E. Minocycline induced autoimmune hepatitis and systemic lupus eryth-ematosus-like syndrome. BMJ. 1996; 312:169–172.

12. Inoue K, Okajima T, Tanaka E, et al. A case of Graves' disease associated with autoimmune hepatitis and mixed connective tissue disease. Endocr J. 1999; 46:173–177.

13. Sato I, Tsunekawa T, Shinohara Y, et al. A case of autoimmune hepatitis with Graves' disease treated by propylthiouracil. Nagoya J Med Sci. 2011; 73:205–209.

14. Duchini A, McHutchison JG, Pockros PJ. LKM-positive autoimmune hepatitis in the western United States: a case series. Am J Gastroenterol. 2000; 95:3238–3241.

15. Hennes EM, Zeniya M, Czaja AJ, et al. International Autoimmune Hepatitis Group. Simplified criteria for the diagnosis of autoimmune hepatitis. Hepatology. 2008; 48:169–176.

16. Weetman AP. Graves' disease. N Engl J Med. 2000; 343:1236–1248.

17. Onji M, Nonaka T, Horiike N, Moriwaki H, Muto Y, Ohta Y. Present status of autoimmune hepatitis in Japan. Gastroenterol Jpn. 1993; 28(Suppl 4):134–138.

18. Mori T, Akamizu T, Kosugi S, et al. Recent progress in TSH receptor studies with a new concept of “autoimmune TSH receptor disease”. Endocr J. 1994; 41:1–11.

19. Biscoveanu M, Hasinski S. Abnormal results of liver function tests in patients with Graves' disease. Endocr Pract. 2000; 6:367–369.

20. Khemichian S, Fong TL. Hepatic dysfunction in hyperthyroidism. Gastroenterol Hepatol (N Y). 2011; 7:337–339.

Fig. 1.

Histologic findings of liver biopsies are consistent with autoimmune hepatitis (H&E, ×200). (A) Severe necroinflammatory activity with marked portal lymphoplasma cell infiltration with occasional eosinophils and mild ductular proliferation are seen within the portal tract. (B) Local infiltration of inflammatory cells within the lobules and damaged hepatocytes are seen, indicating lobular hepatitis.

Fig. 2.

Clinical course of the patient.

Table 1.

Laboratory Data on Admission

Laboratory data	Result
Liver function test
AST (IU/L)	1,282
ALT (IU/L)	1,119
Total bilirubin (mg/dL)	6.4
Direct bilirubin (mg/dL)	5.4
GGT (mg/dL)	150
ALP (IU/L)	136
Albumin (g/dL)	4.0
PT (INR)	1.05
Viral markers
IgM anti-HAV	Negative
HBsAg	Negative
Anti-HBc	Negative
Anti-HBs	Negative
Anti-HCV	Negative
Thyroid function test
TSH	<0.025
Free T4	3.82
T3	421.5
Autoantibodies
Thyroid stimulating antibody	Positive
Anti-LKM	Negative
ANA	1 : 40 negative
Anti-smooth muscle antibody	Negative
AMA	Positive

TSH, thyroid stimulating hormone; Anti-LKM, anti-liver/kidney microsomal type 1; ANA, anti-nuclear antibodies.

Table 2.

Simplified Diagnostic Criteria for AIH¹⁵

Variable	Cutoff ^a	Points
ANA or SM	≥1 : 40	1
ANA or SM	≥1 : 80
Anti-LKM	≥1 : 40	2
Soluble liver antibody	Positive
IgG	> Upper normal limit	1
	>1.10 times upper normal limit	2
Liver histology	Compatible with AIH	1
	Typical AIH	2
Absence of viral hepatitis	Yes	2

AIH, autoimmune hepatitis; ANA, anti-nuclear antibodies; SM, anti- smooth muscle antibodies; Anti-LKM, anti-liver/kidney microsomal type 1.

^a ≥6, probable autoimmune hepatitis; ≥7, definite autoimmune hepatitis.

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