Case report
A 37-year-old female with intermittent palpitations, easy fatigability for 18 years was referred to our hospital with 6 weeks of exertional dyspnea, lower extremity edema. She was diagnosed with Graves’ hyperthyroidism in 2001 and started on methimazole (MMI), but compliance taking the medication was low. She had taken herbal remedies for two years, but the detailed prescription cannot be provided. She admitted and received medical treatment at local hospital 4 weeks ago, however, her condition deteriorated and total bilirubin is about five times higher than normal. Then, she was referred to our hospital. On physical examination, she was afebrile, heart beats at presentation was 105 per minute and blood pressure was 116/65 mmHg. She had mild generalized icterus but no consciousness disturbance,diffusely enlarged thyroid gland without pain. Two red spots on the upper chest were noticed that characterized by central arteriole with radiated blood vessels. Cardiovascular exam revealed an irregular rhythm, systolic murmur at the lower left sternal border, the jugular venous pressure was raised and neck veins engorged. Mild bilateral lower extremity edema was present. A workup for thyroid dysfunction demonstrated raised serum free thyroxine, triiodothyronine levels with suppressed thyroid stimulating hormone (TSH) level and high TSH receptor antibody titers (Table 1). Differential complete blood count showed a low white blood cell count and low absolute neutrophil count. Increased BNP indicated congestive heart failure, cardiac biomarkers were negative for an acute coronary event. Liver chemistries showed mild elevations in aspartate aminotransferase,γ-glutamyl transpeptidase and blood ammonia. Notably, her total bilirubin, direct bilirubin elevated progressively and coagulation disorders were confirmed. The patient also had negative serology for hepatitis A, B, and C. Autoimmunity markers (antinuclear antibody, antimitochondrial antibody, antineutrophil cytoplasmic antibody, anti-smooth-muscle antibody, and anti-liver-kidney microsome antibody) were all negative。The ECG showed atrial fibrillation with ventricular rate at 80 beats/min (given metoprolol, 25mg 2/d), chest radiography showed right pleural effusion, pulmonary congestion and the cardiothoracic ratio was 72%(Figure 1). Transthoracic echocardiogram reported an ejection fraction (EF) of 60% with bilateral atrial and right ventricle enlargement, elevated pulmonary artery pressure, severe mitral and tricuspid regurgitation(Figure 2). Abdominal ultrasonography, computed tomography and magnetic resonance cholangiopancreatography showed no biliary ductal dilation, pancreatic, biliary, or intrahepatic mass, portal vein thrombosis, or findings concerning for primary sclerosing cholangitis. Moderate ascites was found in right sided chest cavity,cavum pericardii,abdomen、pelvic cavity。A thyroid nuclear scan showed a diffuse homogenous increased uptake of radioactive iodine with no background uptake.