Successful Management of Patients with Co-existent Graves' Disease and Autoimmune Hepatitis

Graves' disease may lead to hepatic dysfunction. This is due to the direct effect of increased circulation of thyroid hormones. Graves' disease is associated with other autoimmune diseases, including autoimmune hepatitis. We report four cases of a rare occurrence of both Graves' disease and autoimmune hepatitis. Two female patients underwent radioactive iodine ablation for Graves' disease. Both patients were diagnosed with autoimmune hepatitis with liver biopsy after liver enzymes worsened despite stable thyroid function. Both patients received steroid immunosuppression therapy for autoimmune hepatitis. The first patient improved with return of thyroid function and liver enzymes to normal whereas the second patient's liver disease progressed despite treatment and she eventually required liver transplant. A female patient with concomitantly diagnosed Graves' disease and autoimmune hepatitis was initially treated with steroids and anti-thyroid medication. She then underwent radioactive iodine ablation but ultimately required liver transplant. Another female patient received treatment with immunosuppression and anti-thyroid therapy. She eventually underwent radioactive iodine ablation with normalization of thyroid function and liver profile. This case series illustrates the diagnostic challenge to determine the cause of elevated liver enzymes in patients presenting with both Graves' disease and autoimmune hepatitis. A brief review of the literature on its clinical presentation and diagnosis is discussed.