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Methimazole-induced cholestasis initially obscured by an incidental finding of a large periampullary diverticulum: A
Salomon Chamay1, Ari Alter2, Rooshi Parikh3
1Division of Internal Medicine, Department of Medicine St. Barnabas Hospital Bronx New York USA.
Abstract:
Methimazole is a commonly prescribed drug for hyperthyroidism and is generally well-tolerated, with complications occurring in less than 10% of treated patients. To our knowledge, there are approximately 30 reported cases of drug-induced liver injury (DILI) associated with the use of methimazole in the literature. DILI is a challenging diagnosis and can often mimic many forms of acute and chronic hepatitis. The pattern of liver injury can be hepatocellular, cholestatic, or mixed in nature. The R-value is a useful tool for characterizing the pattern of liver injury, while the Roussel Uclaf Causality Assessment Method (RUCAM) aids with quantifying the likelihood of DILI. The updated version of RUCAM from 2016 was used in this report. We present a case of a 72-year-old female who developed cholestatic DILI secondary to methimazole with a calculated RUCAM score of 8, initially obscured by both imaging and endoscopic findings concerning for hepatobiliary obstruction.
Insights
Methimazole, used for hyperthyroidism, can cause drug-induced liver injury (DILI). This case highlights a rare cholestatic DILI presentation, emphasizing the importance of considering methimazole in differential diagnoses.
Area of Science:
- Hepatology
- Pharmacology
- Internal Medicine
Background:
- Methimazole is a first-line treatment for hyperthyroidism.
- Drug-induced liver injury (DILI) is an uncommon but serious complication.
- DILI diagnosis can be challenging due to varied presentations.
Purpose of the Study:
- To report a rare case of cholestatic DILI caused by methimazole.
- To illustrate the diagnostic challenges in methimazole-induced liver injury.
- To emphasize the utility of RUCAM in assessing DILI causality.
Main Methods:
- Case report of a 72-year-old female patient.
- Utilized the updated Roussel Uclaf Causality Assessment Method (RUCAM) 2016.
- Diagnostic workup included imaging and endoscopic procedures.
Main Results:
- The patient developed cholestatic DILI secondary to methimazole.
- A RUCAM score of 8 indicated a high probability of DILI.
- Initial findings mimicked hepatobiliary obstruction.
Conclusions:
- Methimazole can cause cholestatic DILI, which may be initially misdiagnosed.
- RUCAM is a valuable tool for diagnosing DILI.
- Awareness of methimazole's potential for liver injury is crucial for clinicians.
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