Abstract 44: A rare case of Marine-Lenhart syndrome with rare presentation

Introduction The Marine-Lenhart Syndrome (MLS) is a very rare condition in which patient has Graves' disease (GD) along with autonomic functioning thyroid nodules. GD can have hepatic dysfunction either due to autoimmune etiology, hepatic congestion due to cardiovascular effect or hepatic involvement due to anti thyroid drugs. Here, we present the first ever reported case of MLS presenting as hepatitis. To the best of our knowledge, there are no previous case report on this rare condition with this rare presentation. Case Presentation A 51-year-old female presented with nausea, vomiting and abdominal pain for 3 weeks. She had decreased appetite, malaiseand jaundice for 10 days when presented to us. She has doubtful past history of taking some thyroid medication 5 years back which she took for about an year. Clinical examination revealed that she had icterus, fine tremors, goitre and looked emantiatied at her presentation. She had slight tenderness at right hypochondrium and looked dehyrated with raised temperature. Evaluation Her blood investigation reports also showed deranged Liver funtion tests. The conjugated bilirubin was raised (17 mg/dL). Both SGOT/SGPT (1184/636) and International normalized ratio INR (1.41) were also deranged. The CT scan results revealed the presence of mild hepatomegaly with liver parenchymal disease. The upper GI endoscopy and ECHO was normal. The endoscopic ultrasound reports revealed normal CBD and had no signs of an obstructive cause. HBsAg and HCV tests were negative. FT4 was 84 pmol/L (N 9-21) and TSH was <0.05 mIU/L. The thyrotropin receptor antibody (TRAb) was positive which confirmed the diagnosis of Graves' disease. USG guided biopsy of liver was performed in view of deranged liver funtion test. HPE showed acute liver hepatitis and mixed pattern like DILI. The ANA/ANF antibody and IgG antibodies levels were higher, 79.95 IU (N < 20 IU) and 2048 mg/dl (N 700-1600 mg/dl) respectively. Her provisional diagnosis was GD with autoimmune hepatitis and patient was planned for RIA. Thyroid scan revealed AFTN (autonomous functioning thyroid nodule). Taken all these results together, our final diagnosis was a rare condition of marine Lenhart syndrome with graves' disease and autoimmune hepatitis. Treatment Initially patient was given IV fluids and supportive care. As patient had a deranged LFT and thyrotoxicosis, Lithium at a dose of 300 mg/d was started and it was titrated according to the blood lithium levels. She was given steroids for autoimmune hepatitis. RIA was advised, butpatient did not give consentand Lithium was continued. Patient is euthyroid with normal LFT at present.