Fulminant hepatitis and elevated levels of sIL-2R in thyroid storm

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Summary

We report the case of a 48-year-old man with thyroid storm associated with fulminant hepatitis and elevated levels of soluble interleukin-2 receptor (sIL-2R). Fatigue, low-grade fever, shortness of breath, and weight loss developed over several months. The patient was admitted to the hospital because of tachycardia-induced heart failure and liver dysfunction. Graves’ disease with heart failure was diagnosed. He was treated with methimazole, inorganic iodide, and a β-blocker. On the day after admission, he became unconscious with a high fever and was transferred to the intensive care unit. Cardiogenic shock with atrial flutter was treated with intra-aortic balloon pumping and cardioversion. Hyperthyroidism decreased over 10 days, but hepatic failure developed. He was diagnosed with thyroid storm accompanied by fulminant hepatitis. Laboratory investigations revealed elevated levels of sIL-2R (9770 U/mL). The fulminant hepatitis was refractory to plasma exchange and plasma filtration with dialysis, and no donors for liver transplantation were available. He died of hemoperitoneum and gastrointestinal hemorrhage due to fulminant hepatitis 62 days after admission. Elevated circulating levels of sIL-2R might be a marker of poor prognosis in thyroid storm with fulminant hepatitis.

Learning points:

The prognosis of thyroid storm when fulminant hepatitis occurs is poor.
Liver transplantation is the preferred treatment for fulminant hepatitis induced by thyroid storm refractory to plasma exchange.
Elevated levels of soluble interleukin-2 receptor might be a marker of poor prognosis in patients with thyroid storm.

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Most cited references 6

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The relationship between the thyroid gland and the liver.

Anna Malik, Susanne Hodgson (2002)

Thyroxine and tri-iodothyronine are essential for normal organ growth, development and function. These hormones regulate the basal metabolic rate of all cells, including hepatocytes, and thereby modulate hepatic function; the liver in turn metabolizes the thyroid hormones and regulates their systemic endocrine effects. Thyroid dysfunction may perturb liver function, liver disease modulates thyroid hormone metabolism, and a variety of systemic diseases affect both organs. We highlight the intricate relations between the thyroid gland and the liver in health and disease.

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Thyroid Storm: A Japanese Perspective

Takashi Akamizu (2018)

Background: Thyroid storm (TS) is life threatening. In the mid-2000s, its incidence was poorly defined, peer-reviewed diagnostic criteria were not available, and management and treatment did not seem to be verified based upon evidence and latest advances in medicine. Methods: First, diagnostic criteria were developed based on 99 patients in the literature and seven patients in this study. Then, initial and follow-up surveys were conducted from 2004 through 2008, targeting all hospitals in Japan to obtain and verify information on patients who met diagnostic criteria for TS. Based on these data, the diagnostic criteria were revised, and management and treatment guidelines were created. Results: The incidence of TS in hospitalized patients in Japan was estimated to be 0.20 per 100,000 per year and 0.22% of all thyrotoxic patients. The mortality rate was 10.7%. Multiple organ failure was the most common cause of death, followed by congestive heart failure, respiratory failure, and arrhythmia. In the final diagnostic criteria for TS, the definition of jaundice as serum bilirubin concentration >3 mg/dL was added. Based upon nationwide surveys and the latest information, guidelines for the management and treatment for TS were extensively revised and algorithms were developed. Conclusions: TS remains a life-threatening disorder, with >10% mortality in Japan. New peer-reviewed diagnostic criteria for TS are presented and its clinical features, prognosis, and incidence are clarified based on nationwide surveys. Furthermore, this information helped to establish detailed guidelines for the management and treatment of TS. A prospective prognostic study to validate the guidelines is eagerly anticipated.

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Role of plasma exchange in the thyroid storm.

Clotilde Muller, Peggy Perrin, Bernadette Faller … (2011)

Inadequately treated thyroid storm can lead to death. Therapeutic plasma exchange (TPE) is a suggested treatment when conventional treatments fail, but its indication is not well codified. We report our experience through three explicit cases. Three elderly patients were admitted to our hospital for cardiac or neurologic symptoms due to thyroid storm. After initiation of conventional therapy, TPE was performed with clinical and biological improvement. The speed of symptom resolution varies depending on the severity. This technique must be carried out by experienced medical staff as many complications can occur; nevertheless, in our patients with severe comorbidities, no complications occurred. The action of TPE mainly results from plasma removal of cytokines, putative antibodies, and thyroid hormones and their bound proteins. TPE has a transitory effect and thus should be associated with other thyroid blockers. When there are threatening symptoms, TPE should be done early, without waiting for the efficiency of conventional treatment, since it is the fastest method known for the improvement of the clinical condition. We also suggest starting TPE in case of neurologic symptoms because of very slow and incomplete regression. The Burch and Wartofsky score seems to be a helpful tool in establishing the diagnosis of thyroid storm and for deciding on when to initiate TPE.

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Author and article information

Journal

Journal ID (nlm-ta): Endocrinol Diabetes Metab Case Rep

Journal ID (iso-abbrev): Endocrinol Diabetes Metab Case Rep

Journal ID (hwp): EDM

Title: Endocrinology, Diabetes & Metabolism Case Reports

Publisher: Bioscientifica Ltd (Bristol )

ISSN (Electronic): 2052-0573

Publication date (Electronic): 06 September 2019

Publication date Collection: 2019

Volume: 2019

Electronic Location Identifier: 19-0078

Affiliations

[1 ]Division of Neurology , Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan

Author notes

Correspondence should be addressed to H Yamaguchi; Email: yamahide@ 123456med.miyazaki-u.ac.jp

^*(Y Tanaka and T Uchida contributed equally to this work)

Article

Publisher ID: EDM190078

DOI: 10.1530/EDM-19-0078

PMC ID: 6765318

SO-VID: c8a840c4-f931-47f5-a392-141356f05105

License:

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License..

History

Date received : 21 August 2019

Date accepted : 06 September 2019

Categories

Subject: Adult

Subject: Male

Subject: Asian - Japanese

Subject: Japan

Subject: Heart

Subject: Liver

Subject: Thyroid

Subject: Thyroxine (T4)

Subject: Triiodothyronine (T3)

Subject: TSH

Subject: Liver failure

Subject: Fulminant hepatitis*

Subject: Thyroid storm

Subject: Graves' disease

Subject: Fatigue

Subject: Pyrexia

Subject: Breathing difficulties

Subject: Dyspnoea

Subject: Weight loss

Subject: Tachycardia

Subject: Heart failure

Subject: Atrial fibrillation

Subject: Hyperthyroidism

Subject: Cardiogenic shock

Subject: Cardiomegaly

Subject: Liver dysfunction*

Subject: Goitre

Subject: Hyperhidrosis

Subject: Oedema

Subject: Hypoglycaemia

Subject: Renal failure

Subject: Coagulopathy

Subject: Hyperammonemia*

Subject: Jaundice

Subject: Hypoxia

Subject: Metabolic acidosis

Subject: Soluble IL-2 receptor*

Subject: Alanine aminotransferase

Subject: Aspartate transaminase

Subject: FT4

Subject: CT scan

Subject: Bilirubin

Subject: Transaminase

Subject: X-ray

Subject: Echocardiogram

Subject: Albumin

Subject: Lactate dehydrogenase

Subject: Alkaline phosphatase

Subject: Glucose (blood)

Subject: Creatinine

Subject: Calcium (serum)

Subject: C-reactive protein

Subject: Potassium

Subject: Ammonia

Subject: Brain natriuretic peptide

Subject: FT3

Subject: TSH

Subject: Thyroid antibodies

Subject: Prothrombin time

Subject: Plasma exchange

Subject: Dialysis

Subject: Intra-aortic balloon pumping*

Subject: Methimazole

Subject: Potassium iodide

Subject: Beta-blockers

Subject: Hydrocortisone

Subject: Glucocorticoids

Subject: Landiolol hydrochloride*

Subject: Glucose

Subject: Propylthiouracil

Subject: Cardiology

Subject: Gastroenterology

Subject: Unique/Unexpected Symptoms or Presentations of a Disease

Keywords: adult,male,asian - japanese,japan,heart,liver,thyroid,thyroxine (t4),triiodothyronine (t3),tsh,liver failure,fulminant hepatitis*,thyroid storm,graves' disease,fatigue,pyrexia,breathing difficulties,dyspnoea,weight loss,tachycardia,heart failure,atrial fibrillation,hyperthyroidism,cardiogenic shock,cardiomegaly,liver dysfunction*,goitre,hyperhidrosis,oedema,hypoglycaemia,renal failure,coagulopathy,hyperammonemia*,jaundice,hypoxia,metabolic acidosis,soluble il-2 receptor*,alanine aminotransferase,aspartate transaminase,ft4,ct scan,bilirubin,transaminase,x-ray,echocardiogram,albumin,lactate dehydrogenase,alkaline phosphatase,glucose (blood),creatinine,calcium (serum),c-reactive protein,potassium,ammonia,brain natriuretic peptide,ft3,thyroid antibodies,prothrombin time,plasma exchange,dialysis,intra-aortic balloon pumping*,methimazole,potassium iodide,beta-blockers,hydrocortisone,glucocorticoids,landiolol hydrochloride*,glucose,propylthiouracil,cardiology,gastroenterology,unique/unexpected symptoms or presentations of a disease,september,2019

Data availability:

Keywords: adult, male, asian - japanese, japan, heart, liver, thyroid, thyroxine (t4), triiodothyronine (t3), tsh, liver failure, fulminant hepatitis*, thyroid storm, graves' disease, fatigue, pyrexia, breathing difficulties, dyspnoea, weight loss, tachycardia, heart failure, atrial fibrillation, hyperthyroidism, cardiogenic shock, cardiomegaly, liver dysfunction*, goitre, hyperhidrosis, oedema, hypoglycaemia, renal failure, coagulopathy, hyperammonemia*, jaundice, hypoxia, metabolic acidosis, soluble il-2 receptor*, alanine aminotransferase, aspartate transaminase, ft4, ct scan, bilirubin, transaminase, x-ray, echocardiogram, albumin, lactate dehydrogenase, alkaline phosphatase, glucose (blood), creatinine, calcium (serum), c-reactive protein, potassium, ammonia, brain natriuretic peptide, ft3, thyroid antibodies, prothrombin time, plasma exchange, dialysis, intra-aortic balloon pumping*, methimazole, potassium iodide, beta-blockers, hydrocortisone, glucocorticoids, landiolol hydrochloride*, glucose, propylthiouracil, cardiology, gastroenterology, unique/unexpected symptoms or presentations of a disease, september, 2019

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Fulminant hepatitis and elevated levels of sIL-2R in thyroid storm

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