A Case of Nonthyroidal Illness Syndrome in a Patient with Severe Liver Cirrhosis with Difficult Differential Diagnosis from Central Hypothyroidism

ABSTRACT

BACKGROUND: The nonthyroidal illness syndrome, alternately known as the euthyroid sick syndrome, usually occurs in individuals who have non-thyroidal illness of varying severity. Most prominent is the generally used name the 'low triiodothyronine (T3) syndrome', but recently authors have experienced a case of non-thyroidal illness syndrome in a patient with liver cirrhosis with difficult differential diagnosis from central hypothyroidism. Therefore, we report it with a review of the literature. CASE: A 39-year old female came to our outpatient clinic due to liver cirrhosis. During symptomatic treatment, her pitting edema was changed into non-pitting. She had low levels of serum T3, free thyroxine (FT4) and thyroid-stimulating hormone (TSH) by third-generation assay. The thyroid function test results were same after dopamine was discontinued. To rule out central hypothyroidsm, 24-hour urinary free cortisol was measured and was within normal limits with 41.9microgramml/day (reference intervals 21-85microgram/ml/day). She became worse, then died as a results of hepatic encephalopathy and hepatorenal syndrome complicated from liver cirrhosis. CONCLUSIONS: In patients with nonthyroidal illness, the degree and the rate of reduction in thyroid hormone levels appears to be correlated with the severity of nonthyroidal illness and may predict prognosis in some cases including severe liver diseases. Low serum levels of T3, FT4, TSH in patients with severe non-thyroidal illness should be distinguished from levels in patients with central hypothyroidism. Central hypothyroidism can often be ruled out in patients with severe nonthyroidal illness syndrome by evaluating appropriate elevated levels of cortisol.