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Lee JJ, Park SM, Park KI, Kang K, Lee WW, Kim BK, Kim YS, Yoo I. Clinical and diagnostic characteristics of Hashimoto's encephalopathy: a single-center, retrospective study. Acta Neurol Belg 2024:10.1007/s13760-024-02520-1. [PMID: 38861245 DOI: 10.1007/s13760-024-02520-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/24/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND AND PURPOSE Diagnosing Hashimoto's encephalopathy (HE) is challenging. In contrast to other types of autoimmune encephalitis, HE shows an excellent response to steroid treatment. We aimed to investigate the rates of antithyroid antibodies (ATAs) and probable HE in patients with unexplained mental dysfunction and compare the clinical characteristics between the good- and poor-outcome groups. METHODS We retrospectively reviewed the medical records and electroencephalography (EEG) and neuroimaging findings of patients admitted to the Department of Neurology of our hospital from March 1, 2006, to February 28, 2023. Using our proposed diagnostic criteria for probable HE, we compared the clinical characteristics between the good- and poor-outcome groups. We also investigated the rates of ATA positivity and probable HE. RESULTS In total, 198 patients exhibited altered mentation, rapidly progressive cognitive decline, or myoclonus. ATA tests were performed on 86 patients, and the detection rates of ATAs and probable HE were 29.1% and 25.6%, respectively. Of the 22 patients enrolled, the good- and poor-outcome groups comprised 19 and 3 patients, respectively. Clinical seizures occurred in seven patients. Nonconvulsive status epilepticus on EEG was observed in six patients, all of whom were intractable to antiepileptic drugs. Nineteen of 21 patients (90.5%) treated with immunosuppressants showed good outcomes. CONCLUSIONS HE is a rare clinical disorder, but not as rare as previously thought. When HE is suspected, steroids should be considered the first-line treatment. Early diagnosis and adequate treatment are critical to achieve good outcomes in HE.
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Affiliation(s)
- Jung-Ju Lee
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, 68 Hangeulbisekro, Noweongu, Seoul, 01830, Korea
| | - Soo-Min Park
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, 68 Hangeulbisekro, Noweongu, Seoul, 01830, Korea
| | - Kyung-Il Park
- Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, 152 Teheran-Ro, Gangnam-Gu, Seoul, 06236, Korea.
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, 68 Hangeulbisekro, Noweongu, Seoul, 01830, Korea
| | - Woong Woo Lee
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, 68 Hangeulbisekro, Noweongu, Seoul, 01830, Korea
| | - Byung Kun Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, 68 Hangeulbisekro, Noweongu, Seoul, 01830, Korea
| | - Yong Soo Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, 68 Hangeulbisekro, Noweongu, Seoul, 01830, Korea
| | - Ilhan Yoo
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, 68 Hangeulbisekro, Noweongu, Seoul, 01830, Korea
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Shariff EM. Sudden-onset Encephalopathy: Do not ignore the Possibility of Hashimoto's Encephalopathy. Neurol India 2020; 68:681-683. [PMID: 32643688 DOI: 10.4103/0028-3886.289015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Hashimoto's encephalopathy (HE) is an uncommon neurological disorder of unknown etiology, found in association with thyroid autoimmunity, mostly uncommon in males. The disease occurs primarily in the fifth decade of life and may occur in two forms; a sudden vasculitic type or a progressive subacute type associated with cognitive dysfunction, confusion, and memory loss. We report a case of a 51-year-old Sri Lankan gentleman with no comorbidities who was presented with one episode of the generalized tonic- clonic seizure (GTCs) followed by prolonged agitation and disorientation. His EEG showed generalized slowing while CT scan and MRI brain were unremarkable. CSF examination showed high protein level with normal cell count and glucose. Routine serologic examination showed very high thyroid-stimulating hormone (TSH) level, with significantly high antithyroid antibodies. He was diagnosed as a case of Hashimoto's encephalopathy and treated with a high dose of steroid and showed remarkable improvement.
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Affiliation(s)
- Erum Mubbashir Shariff
- King Fahd Hospital, Department of Neurology, Imam Abdulrahman Binfaisal University, Dammam, Saudi Arabia
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3
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Ercoli T, Defazio G, Muroni A. Status epilepticus in Hashimoto’s encephalopathy. Seizure 2019; 70:1-5. [DOI: 10.1016/j.seizure.2019.06.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/09/2019] [Accepted: 06/12/2019] [Indexed: 11/15/2022] Open
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Montagna G, Imperiali M, Agazzi P, D'Aurizio F, Tozzoli R, Feldt-Rasmussen U, Giovanella L. Hashimoto's encephalopathy: A rare proteiform disorder. Autoimmun Rev 2016; 15:466-76. [PMID: 26849953 DOI: 10.1016/j.autrev.2016.01.014] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 01/22/2016] [Indexed: 12/11/2022]
Abstract
Hashimoto's encephalopathy (HE) is a rare not well understood, progressive and relapsing multiform disease, characterized by seizures, movement disorders, subacute cognitive dysfunction, psychiatric symptoms and responsiveness to steroid therapy. The disorder is generally associated with thyroid diseases and the most common feature is the presence of anti-thyroperoxidase antibodies (TPOAb). Patients are usually euthyroid or mildly hypothyroid at presentation. All age groups can be affected. The pathophysiology is still unclear, especially the link between elevated serum TPOAb and the encephalopathy. Most reported cases occurred in women and girls. Unspecific symptoms, non-pathognomonic laboratory neurophysiology and neuroimaging features make its diagnosis a real challenge for clinicians. The case of a 16 year old boy, with a clinical picture of HE associated with hypothyroidism, demonstrating an excellent response to high dose steroids is presented together with a systematic review of the literature.
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Affiliation(s)
- Giacomo Montagna
- Department of Pediatrics, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Mauro Imperiali
- Department of Laboratory Medicine, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Pamela Agazzi
- Division of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Federica D'Aurizio
- Department of Laboratory Medicine, S. Maria degli Angeli Hospital, Pordenone, Italy
| | - Renato Tozzoli
- Department of Laboratory Medicine, S. Maria degli Angeli Hospital, Pordenone, Italy.
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Luca Giovanella
- Division of Nuclear Medicine and Thyroid Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
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Hashimoto's Encephalopathy with Positive 14-3-3 Protein in the Cerebrospinal Fluid and Atypical Course Mimicking Creutzfeldt-Jakob Disease. Dement Neurocogn Disord 2015. [DOI: 10.12779/dnd.2015.14.4.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Jang JW, Park SY, Park YH, Kim JE, Kim S. Symptomatic aggravation after corticosteroid pulse therapy in definite sporadic Creutzfeldt-Jakob disease with the feature of Hashimoto's encephalopathy. BMC Neurol 2014; 14:179. [PMID: 25196053 PMCID: PMC4172833 DOI: 10.1186/s12883-014-0179-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 09/03/2014] [Indexed: 11/27/2022] Open
Abstract
Background Creutzfeldt-Jakob disease and Hashimoto’s encephalopathy often show similar clinical presentation. Among Creutzfeldt-Jakob disease mimics, Hashimoto’s encephalopathy is particularly important as it is treatable with corticosteroids. Thus, in cases of middle-aged woman diagnosed with probable Creutzfeldt-Jakob disease and who exhibit high titers of antithyroid antibodies, corticosteroid pulse therapy is typically performed with expectations of near complete recovery from Hashimoto’s encephalopathy. Herein, we provide the first case report that exhibited a negative effect of corticosteroid pulse therapy for a patient with Creutzfeldt-Jakob disease with features of Hashimoto’s encephalopathy. Case presentation We report a case of 59-year-old Asian woman with blurred vision, dysarthria, myoclonus, and rapidly progressive dementia. Cerebrospinal fluid showed 14-3-3 protein positive. Electroencephalogram showed periodic sharp waves (1.5 Hz) at the bilateral frontal or occipital areas. Magnetic resonance imaging showed high signal intensities at the bilateral cerebral cortex, caudate nucleus, and putamen. The patient was diagnosed with probable Creutzfeldt-Jakob disease. However, serum analysis showed a high titer of antithyroid antibodies. We started corticosteroid pulse therapy with subsequent aggravation of seizure activity including generalized myoclonus, epilepsia parialis continua, and ballistic dyskinesia, which was effectively treated with clonazepam. Conclusion We provide evidence of a case of Creutzfeldt-Jakob disease that exhibited clinical deterioration after corticosteroid therapy. Although histopathological confirmation with brain biopsy is not easily available in Creutzfeldt-Jakob disease patients, selective initiation of corticosteroid pulse therapy should be considered in cases of uncertain diagnosis for differentiation with Hashimoto’s encephalopathy.
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Napthali K, Boyle M, Tran H, Schofield PW, Peel R, McEvoy M, Oldmeadow C, Attia J. Thyroid antibodies, autoimmunity and cognitive decline: is there a population-based link? Dement Geriatr Cogn Dis Extra 2014; 4:140-6. [PMID: 24987403 PMCID: PMC4067731 DOI: 10.1159/000362716] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Autoimmunity is considered an uncommon but under-recognised cause of cognitive decline. METHODS Serum samples from 3,253 randomly selected subjects enrolled in the Hunter Community Study, aged 55-85 years, were assayed for thyrotropin stimulatory hormone, anti-thyroid peroxidase antibodies (TPO-Ab), anti-nuclear antibodies (ANA) and extractable nuclear antigens (ENA). Cognitive function was assessed using the Audio Recorded Cognitive Screen (ARCS) tool. RESULTS TPO-Ab were found in 8.4% and ANA in 27.9% of the study population, of whom 3% had positive ENA findings. No relationship was found between the ARCS score and either TPO-Ab (coefficient = 0.133; 95% CI -0.20, 0.82, p = 0.616), ANA at a low (coefficient = 1.01; 95% CI -2.58, 0.55, p = 0.203) or a high titre (coefficient = -0.65; 95% CI -2.59, 1.28, p = 0.508), or ENA antibodies (coefficient = 5.12; 95% CI -0.53, 10.77; p = 0.076). CONCLUSIONS Autoantibody findings are common in an aging population and are not associated with cognitive decline.
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Affiliation(s)
- Kate Napthali
- Division of Medicine, John Hunter Hospital, University of Newcastle, Newcastle, N.S.W., Australia
| | - Michael Boyle
- Division of Medicine, John Hunter Hospital, University of Newcastle, Newcastle, N.S.W., Australia
| | - Huy Tran
- Hunter Area Pathology Service, Newcastle, N.S.W., Australia
| | - Peter W Schofield
- Centre for Brain and Mental Health Research, University of Newcastle, Newcastle, N.S.W., Australia ; Hunter Medical Research Institute, University of Newcastle, Newcastle, N.S.W., Australia ; Neuropsychiatry Unit, Hunter New England Local Health District, Newcastle, N.S.W., Australia
| | - Roseanne Peel
- Hunter Medical Research Institute, University of Newcastle, Newcastle, N.S.W., Australia ; Centre for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, N.S.W., Australia
| | - Mark McEvoy
- Hunter Medical Research Institute, University of Newcastle, Newcastle, N.S.W., Australia ; Centre for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, N.S.W., Australia
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, University of Newcastle, Newcastle, N.S.W., Australia ; Centre for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, N.S.W., Australia
| | - John Attia
- Division of Medicine, John Hunter Hospital, University of Newcastle, Newcastle, N.S.W., Australia ; Hunter Medical Research Institute, University of Newcastle, Newcastle, N.S.W., Australia ; Centre for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, N.S.W., Australia
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Encéphalopathie d’Hashimoto. Rev Med Interne 2012; 33:390-5. [DOI: 10.1016/j.revmed.2012.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 01/28/2012] [Accepted: 02/22/2012] [Indexed: 11/21/2022]
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Lee SW, Donlon S, Caplan JP. Steroid Responsive Encephalopathy Associated with Autoimmune Thyroiditis (SREAT) or Hashimoto's Encephalopathy: A Case and Review. PSYCHOSOMATICS 2011; 52:99-108. [DOI: 10.1016/j.psym.2010.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 03/22/2010] [Accepted: 03/23/2010] [Indexed: 10/14/2022]
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Abstract
Cerebrospinal fluid (CSF) is the main component of the brain extracellular space and participates in the exchange of many biochemical products in the CNS. Consequently, CSF contains a dynamic and complex mixture of proteins that reflect the physiological or pathological state of the CNS. Changes in the CSF proteome have been described in various neurodegenerative disorders. These alterations are also thought to reflect pathological changes in the brain, and thus understanding them will contribute to a better awareness of the pathophysiology that underlies these disorders. Proteomics offers a new methodology for the analysis of pathological changes and mechanisms occurring in neurodegenerative processes and provides the possibility of novel biomarker discovery in order to supplement faster, earlier and more precise diagnosis. In general, the following criteria have to be applied in order to qualify a protein or a gene as a potential biomarker: the selected parameters have to be sensitive (able to detect the abnormalities at early stage of disease), specific (to allow differential diagnosis), reproducible with a high positive predictive value, and should allow for disease monitoring as well as a potential therapeutic response. In Creutzfeldt–Jakob disease, two major approaches have been followed that aim to detect the pathological form of the prion protein (PrPSc) in various peripheral tissues, while other approaches look for surrogate parameters that are a consequence of the neurodegenerative process. While the amount of abnormal disease-related PrPSc in CSF and blood in human transmissible spongiform encephalopathies appears to be extremely low, the development of a PrPSc-based biomarker was hampered by technical problems and detection limits. However, a variety of other proteins have been investigated in the CSF, and recently a variety of potential biomarkers have been reported that contribute to clinical diagnosis. Already established markers are 14-3-3, β-amyloid, tau-protein and phosphorylated isoforms, S100b, as well as neuron-specific enolase. Since some of these markers display certain limitations, the search continues. This review summarizes current knowledge of biomarker development in prion diseases and discusses perspectives for new approaches.
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Affiliation(s)
- Joanna Gawinecka
- Department of Neurology, University Medical School, Georg-August University, Göttingen, Germany
| | - Inga Zerr
- Department of Neurology, University Medical School, Georg-August University, Robert-Koch Str. 40, 37075 Göttingen, Germany
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Lopez-Giovaneli J, Moreaud O, Faure P, Debaty I, Chabre O, Halimi S. Cortico-responsive encephalopathy associated with autoimmune thyroiditis (SREAT): about two case reports characterized by a gap between the diagnosis of autoimmune thyroiditis and neurological disorders. ANNALES D'ENDOCRINOLOGIE 2007; 68:173-6. [PMID: 17582380 DOI: 10.1016/j.ando.2007.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Revised: 04/13/2007] [Accepted: 05/03/2007] [Indexed: 10/22/2022]
Abstract
We report two cases of steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT) often called "Hashimoto's encephalopathy" in which the neurological manifestations develop years before or after the Hashimoto's diagnosis. Because of this specific presentation, the etiological diagnosis of this type of encephalopathy can be a difficult task. In our patients there was a gap of 10 to 20 years between the proof of autoimmune thyroiditis and the neurological symptoms. Case reports of this type of presentation are rare in the literature. A dramatic responsiveness to steroids with total recovery, after several relapses, was confirmed 3 years after the end of treatment. We suggest that antithyroid antibodies should be checked in all patients with unexplained acute or subacute encephalopathy even in elderly subjects in whom the most important differential diagnosis with Creutzfeldt-Jacob disease remains rapidly progressive Alzheimer's disease. A brief review of the literature is proposed.
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Affiliation(s)
- J Lopez-Giovaneli
- Département Diabète Urologie Néphrologie Endocrinologie (DUNE), CHU de Grenoble, BP 217, 38043 Grenoble cedex 9, France
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Ferracci F, Carnevale A. The neurological disorder associated with thyroid autoimmunity. J Neurol 2006; 253:975-84. [PMID: 16786216 DOI: 10.1007/s00415-006-0170-7] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Accepted: 01/30/2006] [Indexed: 01/18/2023]
Abstract
The neurological disorder associated with thyroid autoimmunity is an elusive disease that neurologists have learned to recognize in the last few years. The diagnosis is made, after excluding more common diseases, when neuropsychiatric symptoms develop in a patient with high serum concentrations of anti-thyroid antibodies. The clinical presentations of the disease and the many controversial issues surrounding the diagnosis, the pathogenesis, the role of thyroid autoantibodies, and the choice of therapy are reviewed and discussed in the light of the medical literature in English.
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Affiliation(s)
- Franco Ferracci
- Divisione di Neurologia, Ospedale San Martino, Viale Europa, 32100 Belluno, Italy.
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Tamagno G, Federspil G, Murialdo G. Clinical and diagnostic aspects of encephalopathy associated with autoimmune thyroid disease (or Hashimoto's encephalopathy). Intern Emerg Med 2006; 1:15-23. [PMID: 16941808 DOI: 10.1007/bf02934715] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Encephalopathy associated with autoimmune thyroid disease, currently known as Hashimoto's encephalopathy, but also defined as corticosteroid-responsive encephalopathy associated with autoimmune thyroiditis, is a relatively rare condition observed in a small percentage of patients presenting with autoimmune thyroid disease. It consists of a subacute, relapsing-remitting, steroid-responsive encephalopathy characterised by protean neurologic and neuropsychiatric symptoms, diffuse electroencephalographic abnormalities and increased titres of antithyroid antibodies in serum and/or in cerebrospinal fluid. Most of the cases presenting this neurologic complication are affected by Hashimoto's thyroiditis or, less frequently, by other autoimmune thyroid diseases, chiefly Graves' disease. The pathogenesis of this encephalopathy is still unknown and largely debated, because of extremely varied clinical presentation, possibly referable to different aetiologic and pathophysiologic mechanisms, as confirmed by the two clinical cases we report in this paper. Autoimmune aetiology is, however, very likely in view of the well established favourable response to corticosteroid administration. Both vasculitis and autoimmunity directed against common brain-thyroid antigens represent the most probable aetiologic pathways. Clinical manifestations include consciousness changes, neurologic diffuse or focal signs, headache, and altered cognitive function. Although unspecific, cerebral oedema has also been described. Cerebrospinal fluid examination often discloses an inflammatory process, with a mild increase in protein content and occasionally in lymphocyte count. In this review, clinical criteria for the diagnosis of defined, probable, or possible encephalopathy associated with autoimmune thyroid disease are suggested. Corticosteroid therapy currently allows us to obtain rapid remission of disease symptoms, but adverse outcomes as well as spontaneous remissions have also been reported.
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Affiliation(s)
- Gianluca Tamagno
- Medical Clinic 3, Department of Medical and Surgical Sciences, University of Padua, Padua, Italy
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Creutzfeldt CJ, Haberl RL. Hashimoto Encephalopathy: a do–not–miss in the differential diagnosis of dementia. J Neurol 2005; 252:1285-7. [PMID: 15917981 DOI: 10.1007/s00415-005-0832-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2004] [Revised: 01/13/2005] [Accepted: 01/28/2005] [Indexed: 10/25/2022]
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