A case of thyroid crisis occurring with acute hepatic failure and congestive heart failure associated with dilated cardiomyopathy

A 44-year-old man was admitted to the hospital because of gradually worsening dyspnea, fever, cyanosis, jaundice and acute circulatory impairment with atrial fibrillation. The patient had been well until about fifteen years earlier, when tremors and excessive sweating developed. On admission, serum glutamic oxaloacetic transaminase (GOT) and lactate dehydrogenase (LDH) were 11, 454IU·l-1 and 20, 292IU·l-1, respectively. Echocardiography documented a mildly dilated ventricle with diffuse hypokinesis and the left ventricular ejection fraction was 0.2. Because of increased thyroid hormones, undetectable thyroid-stimulating hormone and the clinical course, the patient was diagnosed as having a thyrotoxic crisis due to Graves' hyperthyroidism. Plasma exchange was performed to treat the thyrotoxic crisis and hepatic failure. Thyroid hormones and hepatic enzymes normalized. Although total bilirubin increased to 29mg·dl-1, this parameter also normalized about two months later. We reconfirmed that plasma exchange is very effective in decreasing hyroid hormones to normal levels in hyperthyroidism with congestive heart failure and acute hepatic failure.