Endocrine Abstracts

A 54 year old gentleman with a background of treated B cell lymphoma presented to his practitioner with symptoms of thyrotoxicosis. His thyroid work up confirmed positive thyroid receptor antibodies, and hence treated as Graves’ disease. He was started on carbimazole by his practitioner. After two weeks of initiation of treatment with carbimazole, he presented to his GP with yellowish discoloration of skin, nausea, vomiting and passing dark coloured urine. He was found to have remarkably deranged liver function tests indicating acute liver injury warranting urgent MRCP. MRCP ruled out any obstructive pathology. Non Invasive Liver Screening was unremarkable. Carbimazole was stopped. Patient was started on high dose propranolol and cholestyramine to optimise the symptoms of thyrotoxicosis. Gastroenterology team was consulted and the patient was started on ursodeoxycholic acid with a trial to improve the Liver Functions and reduce the level of bilirubin. Liver function tests were monitored regularly which showed sluggish improvement in weeks. Liver biopsy showed acute cholangitis and cholestatic hepatitis suggesting likely drug induced liver injury. He was started on Enteral feeding to support nutrition during the phase of acute liver injury. Team of gastroenterologists, endocrinologists and dietitians were involved to devise a holistic management plan of the patient to further facilitate the eligibility of the patient to have thyroidectomy eventually. Hepatitis is one of the rarely reported side effects of carbimazole with almost all the reported cases consistent with intrahepatic cholestasis. In the index case, the hepatic injury is reported with a relatively lower dose of carbimazole and within 2 weeks of initiation of carbimazole treatment as compared to other reported cases where the liver damage is evident after months of carbimazole intake and on increasing the dose. So, it is unclear if the hepatic injury is more common with higher doses and longer duration of treatment with carbimazole. Hepatitis being an uncommon side effect of carbimazole, early histological diagnosis is essential for the prompt management of both thyrotoxicosis and liver injury by seeking valuable contribution from endocrinologists, hepatologists and nutrition specialists.