Acute severe jaundice with hepatic encephalopathy due to methimazole

A 50-year-old female patient received oral methimazole 2.5 mg twice daily for hyperthyroidism. About 5 months later,she developed fatigue,yellow urine.Her symptoms progressed to severe jaundiced skin and sclera after 10 days.Laboratory tests revealed the following levels;alanine aminotransferase 54 U/L,aspartate transaminase 105 U/L,total bilirubin 628.6μmol/L,direct bilirubin 542.7μmol/L,total cholesterol 1.7 mmol/L,total protein 60 g/L,albumin 33 g/L,alkaline phosphatase 130 U/L,total bile acid 145.2μmol/L,γ-glutamyl transferase 83.1 U/L.Methimazole was stopped,her regimen was changed to oral prednisone 10 mg four times a day and oral propranolol 10 mg thrice daily.At the same time,liver-protective drugs,and the drugs used for the treatment of jaundice were given.About 1 month later,the patient suddenly developed palpitation,agitation,irrelevant speech,and slow response. Labor-tory tests showed that the blood ammonia level was 25μmol/L,grade I hepatic encephalopathy was diagnosed.And then she was treated with liver-protective drugs,and the drugs used for the treatment of jaundice and hepatic encephalopathy.One week later,her hepatic encephalopathy symptoms improved,and her jaundice was relieved three weeks late.