Acute Liver Failure Associated with Propylthiouracil in a Pregnant 26-Year-Old Woman
A 26-year-old Japanese woman was referred to Chiba University Hospital for the treatment of acute liver failure. Blood tests showed serum alanine aminotransferase (ALT) 399 IU/l, aspartate aminotransferase (AST) 590 IU/l, alkaline phosphatase 677 IU/l, total bilirubin 15.9 mg/dl and prothrombin time international normalized ratio 1.78. She was diagnosed with hyperthyroidism (Graves’ disease) at age 14, and she was treated with MMI 1 year before admission to our hospital. Five months before admission, she started taking PTU instead of MMI in consideration of her upcoming childbirth. Three months before admission (at 4 weeks gestation), mild liver dysfunction appeared (AST 76 IU/l, ALT 88 IU/l and total bilirubin 1.8 mg/dl). At 8 weeks gestation, her liver function test had not improved (AST 72 IU/l, ALT 104 IU/l and total bilirubin 1.6 mg/dl). One week before admission (at 11 weeks gestation), she underwent surgery for miscarriage at the first clinic. Three days before admission, she had developed fatigue and jaundice and was referred to our hospital. The clinical data at admission to our hospital are shown in table . She had no drug hypersensitivities, liver diseases, blood transfusion or history of surgery other than the above. She did not drink alcohol and had no family history of liver disease. Physical examination revealed jaundice but no consciousness disturbance. Ultrasound examination and computed tomography showed a non-atrophic liver and no ascites. There were no positivities for any viral markers (table ). A drug lymphocyte stimulation test for PTU was positive (stimulation index 234%; 100% for control) []. We diagnosed her as acute liver failure associated with PTU, without presenting hepatic encephalopathy. We started medical treatment such as glycyrrhizin, vitamin K and gabexate mesilate administration and made preparations for urgent liver transplantation [, ]. She improved and was discharged 26 days after admission (fig. ).\nDuring her hospitalization, 20 days after admission, liver biopsy was performed (fig. ), and the specimen showed preserved architecture of the liver, with centrilobular necrosis and ceroid granules also being observed, findings compatible with drug-related liver injury.