Severe cholestasis due to a thyrotoxic crisis

Alonso, Silvia Patricia; Millán García, Gloria; Gomes-Porras, Mariana

doi:10.1016/j.medcle.2022.05.018

array:24 ["pii" => "S2387020622004612" "issn" => "23870206" "doi" => "10.1016/j.medcle.2022.05.018" "estado" => "S300" "fechaPublicacion" => "2022-10-21" "aid" => "6017" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2022" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2022;159:e56-e57" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0025775322003608" "issn" => "00257753" "doi" => "10.1016/j.medcli.2022.05.012" "estado" => "S300" "fechaPublicacion" => "2022-10-28" "aid" => "6017" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2022;159:e56-e57" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "Carta al Editor" "titulo" => "Colestasis grave por crisis tirotóxica" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e56" "paginaFinal" => "e57" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Severe cholestasis due to a thyrotoxic crisis" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Silvia Patricia Alonso, Gloria Millán García, Mariana Gomes-Porras" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Silvia Patricia" "apellidos" => "Alonso" ] 1 => array:2 [ "nombre" => "Gloria" "apellidos" => "Millán García" ] 2 => array:2 [ "nombre" => "Mariana" "apellidos" => "Gomes-Porras" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020622004612" "doi" => "10.1016/j.medcle.2022.05.018" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622004612?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775322003608?idApp=UINPBA00004N" "url" => "/00257753/0000015900000008/v1_202210140543/S0025775322003608/v1_202210140543/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2387020622004624" "issn" => "23870206" "doi" => "10.1016/j.medcle.2022.09.003" "estado" => "S300" "fechaPublicacion" => "2022-10-21" "aid" => "6024" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2022;159:403" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "Image in medicine" "titulo" => "Neurocysticercosis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "403" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neurocisticercosis" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 598 "Ancho" => 500 "Tamanyo" => 39162 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Cristian Cusco Cuzco, Juan Domínguez Enríquez" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Cristian" "apellidos" => "Cusco Cuzco" ] 1 => array:2 [ "nombre" => "Juan" "apellidos" => "Domínguez Enríquez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622004624?idApp=UINPBA00004N" "url" => "/23870206/0000015900000008/v1_202210210800/S2387020622004624/v1_202210210800/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020622004600" "issn" => "23870206" "doi" => "10.1016/j.medcle.2022.06.005" "estado" => "S300" "fechaPublicacion" => "2022-10-21" "aid" => "6016" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2022;159:e55" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "Letter to the Editor" "titulo" => "Reply" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "e55" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "David Berlana, Ignacio Cardona-Pascual, J. Bruno Montoro-Ronsano" "autores" => array:3 [ 0 => array:2 [ "nombre" => "David" "apellidos" => "Berlana" ] 1 => array:2 [ "nombre" => "Ignacio" "apellidos" => "Cardona-Pascual" ] 2 => array:2 [ "nombre" => "J. Bruno" "apellidos" => "Montoro-Ronsano" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775322003591" "doi" => "10.1016/j.medcli.2022.06.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775322003591?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622004600?idApp=UINPBA00004N" "url" => "/23870206/0000015900000008/v1_202210210800/S2387020622004600/v1_202210210800/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Letter to the Editor" "titulo" => "Severe cholestasis due to a thyrotoxic crisis" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e56" "paginaFinal" => "e57" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Silvia Patricia Alonso, Gloria Millán García, Mariana Gomes-Porras" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Silvia Patricia" "apellidos" => "Alonso" "email" => array:1 [ 0 => "silvia_94_86@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Gloria" "apellidos" => "Millán García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Mariana" "apellidos" => "Gomes-Porras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Colestasis grave por crisis tirotóxica" ] ] "textoCompleto" => "A thyrotoxic crisis is an acute and potentially fatal complication that manifests with an exaggerated expression of thyrotoxicosis symptoms and can potentially trigger multiorgan failure.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Mortality linked to this entity is estimated at 8%–25%, despite the administration of treatment.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Because severe hepatic failure is an infrequent form of presentation of this condition, a high degree of suspicion and determining the patient’s thyroid function is key in reaching its diagnosis, as the patient will not always have a previous diagnosis that can guide us, and this might be its initial manifestation.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>In this paper we present the case of a 40-year old man, with no relevant personal medical history, who consulted this clinic due to presenting jaundice, generalized malaise, right hypochondrial pain, lower limb edema, ascites, and weight loss. He denied consuming toxic agents, herbal products, or iodine-based contrast agents. His physical examination revealed frank jaundice, flapping tremor, low-grade fever, bilateral exophthalmos, grade 3 goiter, and tachycardia with a hyperdynamic heartbeat, reaching 50 points in the Burch–Wartofsky scale. Blood work revealed a pattern of cholestasis with frank hyperbilirubinemia at the expense of direct bilirubin (total bilirubin 34.70 mg/dl and direct bilirubin 26.93 mg/dl), alanine transaminase 91 U/L (7–40), aspartate transaminase 104 U/L (13–40), gamma-glutamyl transferase 305 U/L (15–85), alkaline phosphatase 534 U/L (45–117), total protein 4.26 g/dl (5.7–8.2), albumin 2.08 g/dl (3.4–4.8), activated partial thromboplastin time 35.7 s (20.6–31), and international normalized ratio (INR) 3.04 (0.8–1.2). Serology tests were negative for hepatotropic viruses, bacteria, and parasites, as was a hepatic autoimmunity test. An abdominal ultrasound was performed, observing a slightly enlarged liver with engorged suprahepatic veins and ascites, with no evidence of space-occupying lesions. A thyroid function test yielded the following values: free thyroxine (FT4) 137.92 pmol/L (11.0022.00), free triiodothyronine (FT3) 21.60 pmol/L (3.10–6.80), thyroid stimulating hormone (TSH) 0.010 μIU/mL (0.400–5.000), and anti-TSH receptor antibodies (TSHrAb) 38.25 IU/mL (<2). A thyroid ultrasound showed images of thyroiditis with significant vascularization of the thyroid gland, and an echocardiogram revealed a moderate mitral prolapse, a mild tricuspid insufficiency, and both biatrial and right ventricular dilatation, which contributed to the presence of fluid overload, and a preserved ejection fraction.Given these findings, he was diagnosed with a thyrotoxic crisis in a patient with unknown Grave’s disease and an associated severe ophthalmopathy, owing to which he was admitted to the intensive care unit. At said unit he started treatment with hydrocortisone, carbimazole, Lugol®, and propranolol with the aim of achieving normalization of his thyroid profile prior to undergoing a total thyroidectomy. Besides being contradicted due to the patient’s diagnosis of severe ophthalmopathy, radioiodine treatment would not have been effective due to the thyroid block achieved with the Lugol® dissolution.Following this procedure, during which a prophylactic tracheostomy had to be performed, the patient remained hospitalized in the intensive care unit until both his thyroid profile and liver function parameters returned to normal, and closure of his tracheostomy was achieved. He was finally discharged from this unit with a normalized liver function and levothyroxine replacement therapy. In addition, he was referred to the Outpatient Cardiology Department for further assessment and a follow-up of his cardiac function following the normalization of his thyroid profile, but a follow-up echocardiogram was not conducted prior to his discharge from the hospital.The clinical case presented in this paper describes a very infrequent form of thyrotoxic crisis presentation: severe, acute liver failure associated with symptomatic cholestasis. Hepatic impairment associated with thyroid disease can range from a slight, asymptomatic elevation in liver enzyme levels to the presence of severe dysfunction linked to a marked elevation of bilirubin levels,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> particularly the conjugated form.The exact mechanism causing the liver damage in patients with thyrotoxicosis is unclear. Hyperbilirubinemia could be a result of the direct action of thyroid hormones on bilirubin metabolism (in which case mainly the indirect form would increase). However, if this increase occurs at the expense of direct bilirubin, it may be related to the existence of concomitant heart failure, which results in impaired hepatic oxygenation due to a decreased arterial flow and venous congestion, thus leading to cholestasis with an accumulation of direct bilirubin.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Finally, if this deteriorated oxygenation persists over time, it would result in necrosis of the centrolobulillar area, which, in turn, would cause a marked increase in the levels of transaminases, which may initially be mild-moderate.In our patient’s case, although the hypercatabolic state produced by the thyroid hormones could have led to an increase in bilirubin levels and hepatic dysfunction, the main triggering factor for the cholestatic liver disease was probably the concomitant heart failure. However, liver function normalization following a total thyroidectomy supports the hypothesis of the influence of thyrotoxicosis in the pathogenesis of cholestasis in this patient.Acute liver failure associated with a thyrotoxic crisis is a real challenge in which a high degree of suspicion is required to be able to start treatment early and consequently avoid a potentially fatal outcome. Therefore, it is crucial to include thyrotoxic crisis in the differential diagnosis of the causes of acute hepatic impairment. This is especially important when there is a known history of thyroid dysfunction, although also in those without this history but with signs and symptoms compatible with an excess of thyroid hormone, as was the case in our patient.FundingNo sources of funding were available for the conduct of this research.Conflicts of interestThe authors of this paper declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thyroid emergencies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N.J. Sarlis" 1 => "L. Gourgiotis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1023/a:1022933918182" "Revista" => array:8 [ "tituloSerie" => "Rev Endocr Metab Disord." "fecha" => "2003" "volumen" => "4" "numero" => "2" "paginaInicial" => "129" "paginaFinal" => "136" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12766540" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673610620375" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "American thyroid association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.S. Ross" 1 => "H.B. Burch" 2 => "D.S. Cooper" 3 => "M.C. Greenlee" 4 => "P. Laurberg" 5 => "A.L. Maia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1089/thy.2016.0229" "Revista" => array:7 [ "tituloSerie" => "Thyroid." "fecha" => "2016" "volumen" => "26" "numero" => "10" "paginaInicial" => "1343" "paginaFinal" => "1421" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27521067" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thyrotoxicosis and thyroid storm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B. Nayak" 1 => "K. Burman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ecl.2006.09.008" "Revista" => array:8 [ "tituloSerie" => "Endocrinol Metab Clin North Am." "fecha" => "2006" "volumen" => "35" "numero" => "4" "paginaInicial" => "663" "paginaFinal" => "686" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17127140" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0002939419302946" "estado" => "S300" "issn" => "00029394" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thyroid storm presenting as acute liver failure in a patient with Graves’ disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.H. Hayat" 1 => "Z. Moazzam" 2 => "I.A. Ziogas" 3 => "A. Yousaf" 4 => "M. Hayat" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.7759/cureus.10333" "Revista" => array:6 [ "tituloSerie" => "Cureus" "fecha" => "2020" "volumen" => "12" "numero" => "9" "paginaInicial" => "e10333" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33052294" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asociación entre hipertiroidismo y patología hepática. Presentación de dos casos y revisión de la literatura" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Parodi" 1 => "J. Montero" 2 => "M.V. Ferretti" 3 => "G. Chiganer" 4 => "S. Lema" 5 => "M. Ferrado" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Glánd Tir Paratir." "fecha" => "2008" "volumen" => "17" "paginaInicial" => "28" "paginaFinal" => "33" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015900000008/v1_202210210800/S2387020622004612/v1_202210210800/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015900000008/v1_202210210800/S2387020622004612/v1_202210210800/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622004612?idApp=UINPBA00004N"]

ISSN: 2387-0206

Launched in 1943, Medicina Clínica is a fortnightly journal aimed at the promotion of clinical research and practice among internal medicine and other specialists. The key characteristics of Medicina Clínica are the scientific and methodological rigor of its manuscripts, the topicality of its contents, and, especially, its practical focus with highly useful information for clinical practice. Medicina Clínica is predominantly interested in publishing original research manuscripts, which are rigorously selected according to their quality, originality, and interest, and also in continued medical education-oriented manuscripts, which are commissioned by the journal to relevant authors (Editorials, Reviews, and Diagnosis and Treatment). These manuscripts contain updated topics with a major clinical or conceptual relevance in modern medicine. The journal adheres to the standards of academic research publications in all aspects including peer-review and ethical principles. Medicina Clínica is included in the General and Internal Medicine category of Thomson Reuters.

See more Open Access Option

Indexed in:

Current Contents/Clinical Medicine, Journal Citation Reports, SCI-Expanded, Index Medicus/Medline, Excerpta Medica/EMBASE, IBECS, IME, MEDES, PASCAL, SCOPUS, SciVerse ScienceDirect

Subscribe:

Impact factor

The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two preceding years.

© Clarivate Analytics, Journal Citation Reports 2022

Impact factor 2023

2.6

Citescore

CiteScore measures average citations received per document published.

Citescore 2023

3.1

SJR

SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SJR 2023

0.371

SNIP

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field.

SNIP 2023

0.511

View more metrics

Journal Information

Previous article | Next article

Vol. 159. Issue 8.