A case of Graves' disease associated with autoimmune hepatitis and mixed connective tissue disease

The patient was a woman of forty-eight. Liver dysfunction was pointed out a t the age of forty-five. She was admitted to hospital because of her hypert hyroidism. Her palmar skin was wet and her fingers were swollen like sausag es. She had a diffuse and elastic hard goiter with a rough surface. The ser um levels of free T-3 (9.6 pg/mL) and free T-4 (3.76 ng/dL) were high and t hat of TSH (0.11 mu U/ mt) was low. The activity of TSH-binding inhibitory immunoglobulin (TBII) was 89%. The uptake rate of I-123 to the thyroid was 55.1% and the uptake pattern was nearly diffuse. The goiter was proved to c ontain several nodules by ultrasonography, but aspiration cytology showed n o malignant cells. She was diagnosed to have Graves' disease with adenomato us goiter. She also had high ALT (34 IU/L) and gamma-globulin (1.97 g/dL). She had positive antinuclear antibody (speckled type), positive anti-riboso mal nuclear protein antibody, and positive LE cell phenomenon. The liver bi opsy revealed mononuclear cell infiltration with fibrosis in the portal are a. These data indicated that she also had autoimmune hepatitis (AIH) and mi xed connective tissue disease (MCTD). The analysis of human leukocyte antig en (HLA) showed positive All which had been reported to relate to Graves' d isease, and positive DR4 which had been reported to relate to AIH and MCTD. These results suggested that HLA would determine susceptibility to three d istinct autoimmune diseases in this case.