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.