γ GTP, γ -glutamyl transpeptidase; Alb, albumin; ALP, alkaline phosphatase; ALT, alanine-aminotransferase; AMON plasma ammonia APTT, activated partial thromboplastin time; AST, aspartate aminotransferase; BE, base excess; BNP, brain natriuretic peptide; BUN, blood urea nitrogen; CK, creatinine kinase; CK-MB, creatinine kinase-muscle-brain isozyme; Cr, creatinine; FT3, free triiodothyronine; FT4, free thyroxine; Hb, hemoglobin; LDL-C, low-density lipoprotein cholesterol LDH, lactate dehydrogenase NEUT neutrophile granulocyte PG, plasma glucose; Plt, platelets; PT, prothrombin time; PTA, Prothrombin activity;PT-INR, prothrombin time international normalized ratio; RBC, red blood cells; TBA, total bile acid, T-Bil, total bilirubin; Tn-I, troponin I; TP, total protein; TRAb, thyrotrophin receptor antibody; TSH, thyroid-stimulating hormone; WBC, white blood cells; Numerals in parentheses are normal values.
She was diagnosed with Graves’ hyperthyroidism accompanied by atrial fibrillation,congestive heart failure,Liver function and coagulation function supported the diagnosis of acute-on-chronic pre-liver failure. She was continued with furosemide and metoprolol, aspirin was ceased because of hemorrhagic tendency. However, symptoms of atrial fibrillation and heart failure did not improve significantly, BNP continued to rise. The treatment plan switched to methimazole cream 5mg (0.1g) 2/day to diminish levels of thyroid hormone, (the concentration-time curves of the novel formulation in a preclinical study demonstrated the concentration of the methimazole cream of neck swearing group was higher than oral group in thyroid gland tissue and action time could be extended by percutaneous administration)bisoprolol 2.5 mg/day to control ventricular rate at 70~90 beats/min, Torasemide injection at 20 mg/day and spironolactone tablets at 40mg/day were admitted, maximum dose of torasemide reached at 80mg/day. Consequently, the body mass steadily decreased to 56 kg, her dyspnea, lower limb edema and other symptoms gradually alleviated. On the 10th day of admission, the electrocardiogram showed that sinus rhythm was restored, and the ventricular rate was maintained at 60 beats/min.
Ademetionine for injection and capsule ursodeoxycholic acid were initialed on the second day of admission. Although her general condition was improving, total bilirubin levels increased progressively (Fig 3) . She was started on daily therapeutic plasma exchange (TPE) on hospital day 4, replacement fluid contained half fresh frozen plasma (FFP) and half 5% albumin was equal in volume to her total plasma volume (about 4L). Intravenous methylpredisolone at 40 mg/day was given for treatment of severe hepatic dysfunction, total bilirubin levels peaked at 279.8μmol/L (direct bilirubin of 177.7μmol/L) on hospital day 11, then the total bilirubin gradually decreased. The serum free triiodothyronine and thyroxine levels were normalized on the twelfth day of admission. She was treated with radioactive iodine at a dose of 50mci as planned after the tenth course of TPE. The patient was discharged home on bisoprolol, oral diuretics, methylpredisolone tablet and capsule ursodeoxycholic acid. By 3 months post discharge, her total bilirubin had also normalized.