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.