IMMUNOGENIC HYPERTHYROIDISM WITH HIGH-OUT PUT HEART-FAILURE AND EARLYCIRRHOTIC TRANSFORMATION OF THE LIVER

History and clinical findings: A 58-year-old woman was admitted becaus e of jaundice, ascites and marked oedema. For three years she had suff ered from nervousness, decreasing fitness and weight loss, which had b een assumed as due to chronic alcoholism. Liver biopsy revealed extens ive fibrosis, in part with early cirrhotic transformation. This was fo llowed by cardiac failure with atrial fibrillation (ventricular rate 1 40/min) and marked pleural effusions. The thyroid was diffusely enlarg ed and there were signs of exophthalmos. Investigations: Bilirubin con centration was 3 mg/dl, lactate dehydrogenase activity was 310 U/l, ch olesterase 1.3 kU/l and the prothrombin test was 21%. The TSH level wa s 0.01 mu U/ml while the free thyroxine level was 4.7 ng/dl and that o f free triiodothyronine 13.5 pg/ml. Chest radiograph revealed cardiome galy, bilateral peripheral pulmonary congestion and pleural effusions to midfield. Right heart catheterization excluded pulmonary hypertensi on; cardiac output was 10 l/min. The thyroid was enlarged on ultrasoun d and diffusely echopoor, as in immune thyroid disease. Treatment and course: Cardiac failure regressed and thyroid function normalized with in ten days on propranolol, 4 x 40 mg and thiamazole 3 x 40 mg daily i ntravenously. Subtotal thyroidectomy was performed three weeks later w ith subsequent thyroid hormone substitution. Liver functions were norm al six months later and ultrasound showed no signs of cirrhotic change and the ascites had resolved. Conclusion: Hyperthyroidism is frequent ly associated with changes in liver functions. In extreme cases, high- output cardiac failure may occure, with liver congestion and clinical as well as histological changes like those in liver cirrhosis.