scholarly journals SUN-502 Graves’Disease and Autoimmune Hepatitis: Management Challenges

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Maria Marta Sarquis Soares ◽  
Luísa Lima Castro Schutze ◽  
Luciana Cristian Coelho Garcia ◽  
Felipe Augusto Azevedo Leão [email protected] ◽  
Lilian Mara Nunes Maia ◽  
...  
Keyword(s):  
Liver Biopsy ◽  
Autoimmune Hepatitis ◽  
Serum Copper ◽  
Thyroid Storm ◽  
Antithyroid Drugs ◽  
Homogeneous Distribution ◽  
Rapid Improvement ◽  
Previous Infection ◽  
Common Etiology ◽  
Infection Episode

Abstract Graves’ disease (GD) is the most common etiology of hyperthyroidism and may be associated with other autoimmune disorders. Case report: A.J.M.N., 27 years old, previously healthy, presented with abdominal discomfort, nausea and headache. She used paracetamol 750mg t.i.d for seven days. After that, she noticed jaundice and sought medical care. On admission, patient was icteric, oriented, afebrile, without signs of heart failure or alterations in the intestinal habit. Admission laboratory tests: AST 1287 U/L (RR<46), ALT 1090 U/L (RR < 50), total bilirubin (TB) 45.66mg/dL (RR<1.3), direct bilirubin 42.22mg/dL (RR<0.8), TSH 0.04 mcUI/ml, FT4 > 6.99 ng/dL (RR< 2.19). Serology for infectious diseases (A, B and C viral hepatitis; cytomegalovirus; Epstein-Bar Virus, syphilis; Dengue virus) were negative. Available antibodies for autoimmune hepatitis (anti-LKM1, anti-mitochondria, anti-smooth muscle, anti-SSB, anti-SSA, anti-Rnp / Sm, anti-DNA) were non-reactive. Ceruloplasmin and serum copper were normal. TRAB 3 IU/L (RR<1.75 IU /L); Thyroid scintigraphy showed homogeneous distribution of parenchymal contrast and regular contours of the gland; 15-minute uptake was 9.19% (RR: 1%-6%). Propranolol (40mg q.i.d) was prescribed. Burch and Wartofsky score was 30 (possible previous infection episode as precipitation factor = 10 points and unexplained jaundice = 20 points). Since the patient did not have diagnostic criteria for thyroid storm and since liver function was greatly altered, we opted to treat the thyroid disease with 12mCi of radioiodine, instead of antithyroid drugs (ATD). Differential diagnosis of the liver disease, whether due to autoimmunity or due to hyperthyroidism itself or both, were considered. Corticosteroid therapy (prednisone 40mg) was added due to the possibility of the coexistence of GD and autoimmune hepatitis previously reported as been 1.8% of the autoimmune hepatitis cases. Liver biopsy was performed 4 days later, and the findings were compatible with this condition. Ten days after prednisone and 20 days after radioiodine, we noticed a drop in TB (45 to 20mg/dL) and liver enzymes (AST= 69 and ALT 106) and she was discharged with normal FT4. Autoimmune hepatitis and GD presents a management challenge because sometimes it is not possible to confirm the etiology before treatment. The abnormalities could have been due to hyperthyroidism itself, since all autoantibodies to autoimmune hepatitis have been ruled out, but liver biopsy was very suggestive of the autoimmune cause. Initiating ATD for rapid improvement of hyperthyroidism could represent a risk due to hepatotoxicity of these drugs. On the other hand, withholding the treatment in cases of hepatic insufficiency due to hyperthyroidism, can have disastrous consequences. The option with beta-blocker, radioiodine and corticosteroid was successful and might be considered in similar cases.

scholarly journals Leveraging Social Networking Sites for an Autoimmune Hepatitis Genetic Repository: Pilot Study to Evaluate Feasibility (Preprint)

2017 ◽  
Author(s):  
Megan Comerford ◽  
Rachel Fogel ◽  
James Robert Bailey ◽  
Prianka Chilukuri ◽  
Naga Chalasani ◽  
...  
Keyword(s):  
Pilot Study ◽  
Liver Biopsy ◽  
Social Networking ◽  
Autoimmune Hepatitis ◽  
Rare Disease ◽  
Social Networking Sites ◽  
Participant Recruitment ◽  
Study Materials ◽  
Immunosuppressant Medications ◽  
Oriented Research

BACKGROUND Conventional approaches to participant recruitment are often inadequate in rare disease investigation. Social networking sites such as Facebook may provide a vehicle to circumvent common research limitations and pitfalls. We report our preliminary experience with Facebook-based methodology for participant recruitment and participation into an ongoing study of autoimmune hepatitis (AIH). OBJECTIVE The goal of our research was to conduct a pilot study to assess whether a Facebook-based methodology is capable of recruiting geographically widespread participants into AIH patient-oriented research and obtaining quality phenotypic data. METHODS We established a Facebook community, the Autoimmune Hepatitis Research Network (AHRN), in 2014 to provide a secure and reputable distillation of current literature and AIH research opportunities. Quarterly advertisements for our ongoing observational AIH study were posted on the AHRN over 2 years. Interested and self-reported AIH participants were subsequently enrolled after review of study materials and completion of an informed consent by our study coordinator. Participants returned completed study materials, including epidemiologic questionnaires and genetic material, to our facility via mail. Outside medical records were obtained and reviewed by a study physician. RESULTS We successfully obtained all study materials from 29 participants with self-reported AIH within 2 years from 20 different states. Liver biopsy results were available for 90% (26/29) of participants, of which 81% (21/29) had findings consistent with AIH, 15% (4/29) were suggestive of AIH with features of primary biliary cholangitis (PBC), and 4% (1/29) had PBC alone. A total of 83% (24/29) had at least 2 of 3 proposed criteria: positive autoimmune markers, consistent histologic findings of AIH on liver biopsy, and reported treatment with immunosuppressant medications. Self-reported and physician records were discrepant for immunosuppressant medications or for AIH/PBC diagnoses in 4 patients. CONCLUSIONS Facebook can be an effective ancillary tool for facilitating patient-oriented research in rare diseases. A social media-based approach transcends established limitations in rare disease research and can further develop research communities.

scholarly journals Autoimmune Hepatitis with Concomitant Idiopathic Thrombocytopenic Purpura Diagnosed by Transjugular Liver Biopsy

2018 ◽  
Vol 2018 ◽  
pp. 1-6
Author(s):  
Hiromi Fukuda ◽  
Kazuhide Takata ◽  
Takanori Kitaguchi ◽  
Ryo Yamauchi ◽  
Hideo Kunimoto ◽  
...  
Keyword(s):  
Platelet Count ◽  
Liver Biopsy ◽  
Autoimmune Hepatitis ◽  
Histological Examination ◽  
Idiopathic Thrombocytopenic Purpura ◽  
Liver Dysfunction ◽  
Severe Thrombocytopenia ◽  
Percutaneous Liver Biopsy ◽  
Thrombocytopenic Purpura ◽  
Transjugular Liver Biopsy

Patients with autoimmune hepatitis (AIH) may sometimes have concomitant idiopathic thrombocytopenic purpura (ITP). Severe thrombocytopenia in ITP interferes with percutaneous liver biopsy for pathological diagnosis of AIH. Here, we report a case of AIH with ITP in a 63-year-old woman. The patient presented to our hospital with liver dysfunction and thrombocytopenia. For histological examination, transjugular liver biopsy (TJLB) was performed, leading to a diagnosis of AIH. Corticosteroids treatment led to an improvement in her liver enzyme levels and platelet count. In conclusion, patients with AIH may sometimes have concomitant ITP. TJLB was effective for making the diagnosis of AIH with severe thrombocytopenia due to ITP.

scholarly journals Prospective Study of Plasmodium vivax Malaria Recurrence after Radical Treatment with a Chloroquine-Primaquine Standard Regimen in Turbo, Colombia

2016 ◽  
Vol 60 (8) ◽  
pp. 4610-4619 ◽  
Author(s):  
Lina Zuluaga-Idárraga ◽  
Silvia Blair ◽  
Sheila Akinyi Okoth ◽  
Venkatachalam Udhayakumar ◽  
Paula L. Marcet ◽  
...  
Keyword(s):  
Plasmodium Vivax ◽  
Standard Regimen ◽  
High Genetic Diversity ◽  
Content Type ◽  
Longitudinal Observational Study ◽  
High Incidence ◽  
Plasmodium Vivax Malaria ◽  
Previous Infection ◽  
First Recurrence ◽  
Infection Episode

ABSTRACTPlasmodium vivaxrecurrences help maintain malaria transmission. They are caused by recrudescence, reinfection, or relapse, which are not easily differentiated. A longitudinal observational study took place in Turbo municipality, Colombia. Participants with uncomplicatedP. vivaxinfection received supervised treatment concomitantly with 25 mg/kg chloroquine and 0.25 mg/kg/day primaquine for 14 days. Incidence of recurrence was assessed over 180 days. Samples were genotyped, and origins of recurrences were established. A total of 134 participants were enrolled between February 2012 and July 2013, and 87 were followed for 180 days, during which 29 recurrences were detected. The cumulative incidence of first recurrence was 24.1% (21/87) (95% confidence interval [CI], 14.6 to 33.7%), and 86% (18/21) of these events occurred between days 51 and 110. High genetic diversity ofP. vivaxstrains was found, and 12.5% (16/128) of the infections were polyclonal. Among detected recurrences, 93.1% (27/29) of strains were genotyped as genetically identical to the strain from the previous infection episode, and 65.5% (19/29) of infections were classified as relapses. Our results indicate that there is a high incidence ofP. vivaxmalaria recurrence after treatment in Turbo municipality, Colombia, and that a large majority of these episodes are likely relapses from the previous infection. We attribute this to the primaquine regimen currently used in Colombia, which may be insufficient to eliminate hypnozoites.

scholarly journals THERAPEUTIC PLASMA EXCHANGE AS A BRIDGE TO TOTAL THYROIDECTOMY IN PATIENTS WITH SEVERE THYROTOXICOSIS

2020 ◽  
Vol 6 (1) ◽  
pp. e14-e18
Author(s):  
Kelsey Tieken ◽  
Ameena Madan Paramasivan ◽  
Whitney Goldner ◽  
Ana Yuil-Valdes ◽  
Abbey L. Fingeret
Keyword(s):  
Total Thyroidectomy ◽  
Plasma Exchange ◽  
Medical Management ◽  
Response To Therapy ◽  
Therapeutic Plasma Exchange ◽  
Thyroid Storm ◽  
Antithyroid Drugs ◽  
Average Percentage ◽  
The Mean ◽  
Definitive Management

Objective: Graves disease is the most common cause of thyrotoxicosis. Medical management is the first-line treatment but may be contraindicated or ineffective. In patients with severe, refractory thyrotoxicosis therapeutic plasma exchange (TPE) may be indicated as a bridge to thyroidectomy. Methods: We present 3 cases of thyrotoxicosis refractory to medical management that were successfully treated with TPE and subsequent total thyroidectomy, and provide an analysis of the response to therapy via a change in free thyroxine (fT4) levels throughout their treatment course. Results: The average change in fT4 per liter of fluid exchanged was 0.37 ng/dL (SD = 0.08) and the average percentage change of fT4 after each treatment was 20.7% (SD = 8.28). The mean decrease in fT4 after 4 TPE treatments was 57.4%. All patients successfully underwent total thyroidectomy without complication and were discharged from the hospital. Conclusion: TPE should be considered for thyrotoxic patients with severe hyperthyroidism or thyroid storm refractory to medical management or contraindications to antithyroid drugs who need a bridge to total thyroidectomy. In these cases, TPE was a safe and effective treatment that enabled definitive management with thyroidectomy and may be considered in other patients with severe refractory hyperthyroidism or thyrotoxicosis.

scholarly journals THYROID ABSCESS AFTER INJECTION OF HEROIN INTO THE NECK COMPLICATED BY THYROID STORM

2020 ◽  
Vol 6 (4) ◽  
pp. e183-e188
Author(s):  
Christine Mathai ◽  
Anthony Coppola ◽  
Cherie Lisa Vaz
Keyword(s):  
Drug Use ◽  
Reference Range ◽  
Free Thyroxine ◽  
Intravenous Drug ◽  
Thyroid Storm ◽  
Antithyroid Drugs ◽  
Intravenous Drug Use ◽  
Surgical Drainage ◽  
Thyroid Abscess ◽  
The Right

Objective: Our objective is to present a case of thyroid abscess complicated by thyroid storm secondary to intravenous drug use. Cases of thyroid abscess causing thyrotoxicosis are rare. This is the first report of thyroid abscess from intrathyroidal injection of illicit drugs resulting in thyroid storm. Methods: We used biochemical evaluation, computed tomography (CT), and ultrasound to assess the thyroid abscess. Treatment included antithyroid drugs, steroids, antibiotics, and surgical drainage. Results: A 28-year-old female presented with neck pain and fever after injecting heroin into her neck. CT showed bilateral thyroid abscesses measuring 3.0 cm on the left and 2.0 cm on the right. Thyroid-stimulating hormone (TSH) was 0.40 mIU/L (reference range is 0.34 to 5.60 mIU/L). She left against medical advice, then returned with worsening symptoms. CT showed multiloculated, bilateral thyroid abscess measuring 8.6 cm on the left and 5.3 cm on the right. She suffered a cardiac arrest and was resuscitated. Her white blood cell count was 25.9 × 103 cells/mL, TSH <0.01 mIU/L, free thyroxine was 4.25 ng/dL (reference range is 0.89 to 1.76 ng/dL), triiodothyronine was 96 ng/dL (reference range is 70 to 204 ng/dL), and thyroid-stimulating immunoglobulin was <89% (reference range is <140%). She had fever, tachycardia, heart failure, and elevated bilirubin confirming a diagnosis of thyroid storm by Japan Thyroid Association criteria and Burch-Wartofsky score. She was treated with propylthiouracil, hydrocortisone, and antibiotics. Two days later her TSH was <0.005 mIU/L, free thyroxine was 3.06 ng/dL, and triiodothyronine was 62.0 ng/dL. Ultrasound showed enlarged, heterogeneous thyroid with loculated fluid collections. Following surgical abscess drainage, her thyroid function normalized and progressed to hypothyroidism. Conclusion: We conclude that thyroid abscess can be a life-threatening complication of intravenous drug use as it can precipitate thyroid storm. Along with surgical drainage of the abscess, successful management includes antithyroid drugs, antibiotics, and steroids to control thyrotoxicosis, infection, and inflammation.

Patients With Typical Laboratory Features of Autoimmune Hepatitis Rarely Need a Liver Biopsy for Diagnosis

2011 ◽  
Vol 9 (1) ◽  
pp. 57-63 ◽  
Author(s):  
Einar Björnsson ◽  
Jayant Talwalkar ◽  
Sombat Treeprasertsuk ◽  
Matthias Neuhauser ◽  
Keith Lindor
Keyword(s):  
Liver Biopsy ◽  
Autoimmune Hepatitis ◽  
Laboratory Features

Diagnostic Criteria for Autoimmune Hepatitis: Scores and More

2015 ◽  
Vol 33 (Suppl. 2) ◽  
pp. 47-52 ◽  
Author(s):  
Ansgar W. Lohse
Keyword(s):  
Liver Biopsy ◽  
Autoimmune Hepatitis ◽  
Diagnostic Criteria ◽  
Clinical Use ◽  
Serological Markers ◽  
Diagnostic Score ◽  
Different Populations ◽  
International Autoimmune Hepatitis Group ◽  
Patient’S History ◽  
Diagnostic Scores

The diagnosis of autoimmune hepatitis is a clinical diagnosis that combines the patient's history, clinical examination, laboratory and serological markers and the results of a liver biopsy. As the clinical spectrum of autoimmune hepatitis is very wide, making the diagnosis can sometimes be difficult, especially in non-expert hands. Diagnostic scores can help in making the diagnosis, and the simplified diagnostic score of the International Autoimmune Hepatitis Group has a sensitivity and specificity of around 90% in the different populations that have been studied. Therefore, it can be very helpful in everyday use, but nonetheless for some patients the score is not good enough. Limitations are patients with very acute presentations as well as atypical cases. In such cases, a trial of monotherapy with steroids and quick tapering of the steroids is recommended. If the disease responds well to treatment, but recurs after tapering the steroids, the diagnosis of autoimmune hepatitis is confirmed. In addition to its clinical use, diagnostic scores can also be helpful in defining the unified criteria in order to make scientific studies comparable.

Parvovirus B19 Myocarditis: Looking Beyond the Heart

2019 ◽  
Vol 23 (2) ◽  
pp. 158-162
Author(s):  
Jaume Izquierdo-Blasco ◽  
María Teresa Salcedo Allende ◽  
Maria Gemma Codina Grau ◽  
Ferran Gran ◽  
Elena Martínez Sáez ◽  
...  
Keyword(s):  
Heart Failure ◽  
Endothelial Cells ◽  
Autoimmune Hepatitis ◽  
Acute Myocarditis ◽  
Pediatric Population ◽  
Parvovirus B19 ◽  
Human Parvovirus B19 ◽  
Common Etiology ◽  
Disseminated Disease ◽  
Ischemic Encephalopathy

Human parvovirus B19 represents the most common etiology of myocarditis in the pediatric population. Although it usually causes a benign exanthematic viral infection, parvovirus B19 may also present as disseminated disease with tropism for the myocardium, causing heart failure with high mortality. We present the case of a 2-year-old patient with fulminating acute myocarditis in whom the histological, immunophenotypic, and microbiological findings in necropsy showed multiorgan involvement caused by parvovirus B19. The autopsy revealed changes due to infection with parvovirus B19 as well as hypoxic-ischemic and secondary autoimmune changes. Medullary aplasia was observed, transmural lymphocyte myocarditis, lymphocytosis in the dermis with endothelial cells positive for parvovirus B19 in immunohistochemistry, cholestatic hepatitis due to ischemia and autoimmune hepatitis, lymphadenitis, and signs of hemophagocytosis. We also found hypoxic-ischemic encephalopathy.

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