Intended for healthcare professionals

Practice Lesson of the Week

Hypothyroidism in a patient with non-alcoholic fatty liver disease

BMJ 2011; 342 doi: (Published 06 January 2011) Cite this as: BMJ 2011;342:c7199

Cushing's syndrome and NAFLD

The majority of cases of NAFLD are due to the metabolic syndrome with
insulin resistance thought to be a key feature of the pathogenesis. The
authors rightly point out that there are other endocrine causes but they
do not mention Cushing's syndrome.

Cushing's syndrome mirrors many of the features of the metabolic
syndrome (central obesity, hypertension, insulin resistance and
dyslipidaemia) and is associated with a 20% prevalence of NAFLD (1).
Glucocorticoids have a direct effect on hepatic lipid accumulation by
promoting lipogenesis and inhibiting fatty acid beta-oxidation (2).
Although it is a rare condition it can easily be overlooked in NAFLD
patients and it is therefore worth looking out for clinical features (moon
face, striae, dorsocervical fat pad, proximal muscle weakness) and also
considering the diagnosis in those with resistant hypertension.

Hypercortisolism suppresses thyroid function and is also associated
with autoimmune thyroid disease (3). Thus the search for an underlying
endocrine cause may not always end with the identification of
hypothyroidism in association with NAFLD.

1) Rockall AG, Sohaib SA, Evans D, Kaltsas G, Isidori AM, Monson JP
et al. Hepatic steatosis in Cushing's syndrome: a radiological assessment
using computed tomography. Eur J Endocrinol. 2003 149:543-548

2) Letteron P, Brahimi-Bourouina N, Robin MA, Moreau A, Feldmann G,
Pessayre D. Glucocorticoids inhibit mitochondrial matrix acyl-CoA
dehydrogenases and fatty acid beta-oxidation. Am J Physiol. 1997 272:G1141

3) Niepomniszcze H, Pitoia F, Katz SB, Chervin R, Bruno OD. Primary
thyroid disorders in endogenous Cushing's syndrome. Eur J Endocrinol. 2002

Competing interests: No competing interests

09 January 2011
Lee C Claridge
Wellcome Trust Clinical Research Fellow
Centre for Liver Research, University of Birmingham, UK