SHM Converge Scientific Abstract ePoster Gallery-Not So Mellow Yellow: a Curious Case of Hyperbilirubinemia

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This case describes a 55-year-old man with ischemic cardiomyopathy and hypertension who presented with one week of abdominal bloating, jaundice, and leg edema. Initial concern was for hepatobiliary disease because he had severe hyperbilirubinemia and mild liver enzyme abnormalities: total bilirubin 18.4 mg/dL, direct bilirubin 13 mg/dL, AST 84 U/L, ALT 106 U/L, alkaline phosphatase 132 U/L, and INR 1.4. However, extensive evaluation for common liver and biliary causes was negative, including viral hepatitis, CMV, EBV, HIV, autoimmune markers, ferritin, ceruloplasmin, liver ultrasound, and MRCP.<br /><br />The key diagnostic clue was thyroid testing, which showed marked hyperthyroidism with a suppressed TSH of 0.01 and elevated free T4 of 5.29. Thyroid antibodies were positive, supporting Graves disease. The case highlights that hyperthyroidism can cause liver injury, most often in a hepatocellular pattern, but occasionally with severe cholestasis and marked jaundice. Proposed mechanisms include increased mitochondrial oxygen consumption, free radical production, oxidative stress, hepatocyte injury, apoptosis, and cholestasis.<br /><br />Treatment was started with methimazole despite its known potential for hepatotoxicity, because controlling the thyroid disease was judged more important, especially given the severity of cholestasis and risk of thyroid storm. After several weeks of therapy, the patient’s bilirubin improved from 18.4 to 9.7 mg/dL, and free T4 improved from 5.29 to 0.73.<br /><br />The main teaching point is that severe jaundice and abnormal liver tests are not always due to primary liver or biliary disease. When the usual workup is unrevealing, clinicians should consider endocrine causes such as hyperthyroidism, since timely treatment can significantly improve both liver tests and overall symptoms.

Asset Subtitle

Shaw-Ming Lin

Meta Tag

Author List Shaw-Ming Lin

Category Clinical Vignettes

Concept Hyperbilirubinemia

Concept Hyperthyroidism

Concept Liver Test Abnormality

Concept Jaundice

Concept Thyroid-Stimulating Hormone

Distinguished Non-Finalist

Presenter Organization University of Pennsylvania

Presenting Author Shaw-Ming Lin

Track Adult

Keywords

hyperthyroidism

Graves disease

cholestasis

jaundice

hyperbilirubinemia

methimazole

liver injury

thyroid storm

ischemic cardiomyopathy

abnormal liver tests

Hyperbilirubinemia

Hyperthyroidism

Liver Test Abnormality

Jaundice

Thyroid-Stimulating Hormone