Don’t Forget the Thyroid: Graves’ Disease

An atypical presentation can confound the diagnosis, and that is what happened when a 33-year-old African-American woman presented to another hospital with a 3-month history of worsening abdominal pain. She had been in good health until she started experiencing persistent abdominal pain and distension associated with nausea, vomiting, loose stools, decreased appetite, and weight loss. Her past medical history was significant for an episode of deep venous thrombosis during pregnancy and an unevaluated thyroid nodule. She had no history of heavy alcohol or intravenous drug use, and her family history was unremarkable. Unemployed, she was taking classes at the local community college. Her clinical picture at the outside hospital was consistent with liver disease.

The patient’s initial physical examination showed jaundice, abdominal distension and tenderness, and a positive fluid wave. Her work-up at the first hospital revealed a persistently-elevated international normalized ratio (INR) despite several units of fresh frozen plasma and vitamin K. In addition, she had an increased alkaline phosphatase level; other liver enzyme levels were normal. Viral hepatitis and autoimmune antibody panels were negative. Sinusoidal congestion suggestive of Budd Chiari syndrome was evident after a hepatic biopsy, but a hepatic duplex scan revealed normal blood flow and an overall impression of a liver within normal limits. Because her physicians were concerned that she was in acute liver failure, she was transferred to our hospital for further evaluation of hepatic failure and possible liver transplant.

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— Aroop Pal, MD, Margaret Le, BS, Leland Graves, MD

This article originally appeared in the March 2013 issue of The American Journal of Medicine.