Jaundice: A Thyroid Problem?

Excerpt

A 19-year-old Native American male with a history of vitiligo and appendectomy was evaluated by his primary care physician (PCP) with complaints of worsening tachycardia, tremulousness, and a 45-pound unintentional weight loss all occurring over 6 weeks. Since these developments had been noticed by his mother and sister, both of whom had suffered from hyperthyroidism, they urged him to discuss them with his primary care physician. Laboratory tests of thyroid function revealed serum concentrations of thyroid stimulating hormone (TSH) of 0.1 µIU/mL (0.358–3.740) and free thyroxine (fT4) 6.9 ng/dL (0.7–1.6). Treatment was begun with propranolol 20 mg, p.o., t.i.d. for symptomatic hyperthyroidism, pending an urgent consultation with the endocrinology service. Several days after his first meeting with his PCP, he reported the passage of dark urine for 4 days, yellowish discoloration of his skin and eyes for 3 days, and, on reflection, reported itching of his skin, present for 3 weeks. Additional laboratory test results now revealed serum concentrations of total bilirubin 5.5 mg/dL (0.3–1.2), aspartate aminotransferase (AST) 223 U/L (6–38), and alanine aminotransferase (ALT) 258 U/L (13–63); alkaline phosphatase and γ-glutamyl transpeptidase were not measured or recorded. Although on questioning he complained of intolerance to heat, but no dyspnea, chest or neck discomfort or hyperactivity, he reported that 2 weeks previously he had experienced several days of watery diarrhea that had now resolved. His medication history included a single intramuscular injection of 1.2 million units of penicillin G given one week previously for a sore throat due to a presumed streptococcal throat infection. Onset of the jaundice occurred 3 days later. Apart from the propranolol and penicillin, he had taken no other medications, supplements, herbal products, or any drugs of abuse. Given recently diagnosed hyperthyroidism, elevated liver enzyme concentrations in serum, and pruritus with painless jaundice, he was hospitalized for further evaluation. …