A Case of Autoimmune Hepatitis Combined with Graves' Disease / 대한소화기학회지

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 microIU/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.

Diagnostic Value of a Chimeric TSH Receptor (Mc4)-Based Bioassay for Graves' Disease

BACKGROUND/AIMS: Graves' disease (GD) is caused by thyroid-stimulating hormone receptor (TSHR) and thyroid-stimulating immunoglobulin (TSI). We used a recently introduced, technically enhanced TSI bioassay to assess its diagnostic value and determine the cut-off in patients in high iodine intake area. METHODS: In a cross-sectional setting, we collected serum from 67 patients with untreated GD, 130 with GD under treatment, 22 with GD in remission, 42 with Hashimoto's thyroiditis, 12 with subacute thyroiditis, 20 with postpartum thyroiditis, and 93 euthyroid controls. TSI was measured using the Thyretaintrade mark bioassay, which is based on Chinese hamster ovary cells transfected with chimeric TSHR (Mc4). TSI levels are reported as a specimen-to-reference ratio percentage (SRR%). RESULTS: The TSI levels in patients with GD (either treated or not) were significantly higher than those of the remaining patients (p < 0.05). The new bioassay showed a sensitivity of 97.0% and a specificity of 95.9% with a cut-off value of 123.0 SRR% for GD. A weak correlation was found between TSI and thyrotropin-binding inhibiting immunoglobulin (TBII) (rs = 0.259, p = 0.03), but no correlation was found between TSI and tri-iodothyronine or free thyroxine. CONCLUSIONS: The Mc4-CHO bioassay showed comparable diagnostic value for GD with the conventional TBII assay. We propose a cut-off of 123.0 SRR% in areas where iodine intake is high.

Subclinical hypothyroidism in lithium-treated psychiatric patients in Tehran, Islamic Republic of Iran

We investigated thyroid function in 46 [20 female and 26 male] psychiatric outpatients on lithium treatment by assessing triiodothyronine, thyroxine and thyroid stimulating hormone [TSH] levels. The presence of thyroid antibodies [anti-thyroid peroxidase and anti-thyroglobulin] was also assessed. Out of the 46 patients, 8 [17%] displayed overt hypothyroidism. Of the remaining patients, subclinical hypothyroidism was found in 16 patients [35%] and euthyroidism in 22 [48%]. Thyroid antibodies were present in 6 patients in the euthyroid group and 5 patients in the hypothyroid group. The Pearsor product-moment correlation results indicated positive association between TSH level and duration of lithium use and age of the patients with subclinical hypothyroidism. Duration of lithium use and age could be a reasonable indicator for screening asymptomatic patients for subclinical hypothyroidism after starting lithium treatment

Prognostic significance of thyroid antibodies in hyperthyroid patients treated with antithyroid drugs.

Lymphocytic infiltration of the thyroid gland in patients with hyperthyroidism is associated with the presence of serum antithyroidal microsomal antibodies (TMA) and serum antithyroglobulin antibodies (TGA). The aim of this study was to evaluate the clinical significance of TMA and TGA during and after treatment of hyperthyroidism with antithyroidal drugs. One hundred and fifty-four hyperthyroid patients were treated for 18 months with methimazole and then followed up for 18 months or more (mean, 24.8 +/- 12.6 months). Patients were classified into three group. group I, patients negative for TGA and TMA before and during 18 months of treatment, group II patients positive for TMA but negative for TGA before and during 18 months treatment and group III patients who were positive for both TGA and TMA before and during treatment. The relapse rates after discontinuation of treatment in these group were 44.7% (17 of 38), 29% (18 of 62) and 11.1% (6 of 54), respectively. The value in group I was significantly higher than that in group III (P < 0.01). These results show that presence of TMA and TGA influence the prognosis of patients with hyperthyroidism treated with methimazole with regard to relapse. Those patients who had both antibodies were least likely to have a relapse and those who had neither antibody before and during treatment were most likely to have a relapse of hyperthyroidism.

Thyroid stimulating immunoglobulin in hyperthyroidism

This study was carried out on 20 patients with hyperthyroidism. The diagnosis of hyperthyroidism was based on clinical, biochemical and isotopic studies. Sixteen patients were diagnosed as Gravs' disease and four patients as toxic nodular goiter [two had solitary hot nodule and two had multinodular goiter], Thyroid stimulating immunoglobulin estimation revealed normal levels in all patients with toxic nodular goiter; while-13-patients [81%] with Gravs' disease showed high level of thyroid stimulating immunoglobulin. Six months after radioactive iodine therapy, all patients with previously high levels of thyroid stimulating immunoglobulin showed reduction in their serum levels to reach a normal value in 6 of them [46%] and levels above normal range in 7 [54%]. This finding suggests that radioactive iodine therapy may have an immunoregulatory effect in cases of Gravs' disease