Hashimoto's encephalopathy: Report of three cases

Hashimoto's encephalopathy with cerebellar ataxia as the main symptom: A case report and literature review

Hashimoto's encephalopathy (HE), also known as steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT), has a variety of clinical manifestations, with various neuropsychiatric characteristics, including tremors, transient aphasia, seizures, altered consciousness, myoclonus, cognitive impairment, and psychiatric manifestations. The hallmark presenting feature is a non-specific encephalopathy characterized by alteration of mental status and consciousness ranging from confusion to coma and impaired cognitive function, while those with cerebellar ataxia as the main manifestation is rare. We reported a case of Hashimoto's encephalopathy with cerebellar ataxia as the main manifestation, elevated anti-thyroid antibodies (anti-TPO/TG), and normal thyroid function. The symptoms of cerebellar ataxia improved after steroid treatment. Meanwhile, we reviewed the clinical features of 20 representative cases of HE with cerebellar ataxia as the core symptoms. In conclusion, based on our case findings and literature review, the diagnosis of HE should be suspected in cases of encephalopathy without an obvious cause, to quickly start an effective treatment.

Therapeutic plasma exchange in clinical pediatric neurology practice: Experience from a tertiary referral hospital

OBJECTIVE

This study aims to retrospectively evaluate the long-term efficacy, tolerability, and safety of therapeutic plasma exchange (TPE) in children with various neuroimmunological disorders.

METHODS

This analysis was a single-center, retrospective cohort study of pediatric patients with neuroimmunological events undergoing TPE procedures in a tertiary referral center.

RESULTS

There were 23 patients, 14 boys (60.9%), aged at diagnosis onset 8 months to 16.8 years. The main indications of TPE were Guillain-Barré syndrome (GBS, n = 8), autoimmune encephalitis (n = 5), febrile infection-related epilepsy syndrome (FIRES, n = 4), and acute disseminated encephalomyelitis (ADEM, n = 3). There was no life-threatening complication due to the TPE procedures. Eight (34.8%) of 23 patients experienced 13 (7%) complications in 186 TPE procedures, mostly electrolyte disturbances (n = 5). None of patients discontinued TPE due to complications. Two (8.7%) of 23 patients had marked improvement, 6 (26.1%) had moderate and 11 (47.8%) had mild improvement after TPE. The last follow-up visit revealed neurological sequelae in 12 (52.2%) patients. Therapeutic plasma exchange was found to be more effective on GBS, autoimmune encephalitis and myasthenia gravis, less effective on ADEM and FIRES. There was no correlation between improvement with TPE and clinical parameters, including age, sex, diagnosis, disease duration before TPE, presence of intubation, and length of stay in the intensive care unit and hospital.

CONCLUSION

Therapeutic plasma exchange was found to be effective and well-tolerated in children with various types of neuroimmunological disorder, with at least mild improvement in approximately 80% of the patients and no life-threatening complications.

Hashimoto’s Encephalopathy Revealed by Hypochondriacal Delusion: A Case Report Involving a Male Patient

Hashimoto’s encephalopathy (HE) is a rare autoimmune disorder. It associates encephalopathy with autoimmune thyroiditis, presenting abnormal elevations of thyroid antibodies. It is more common in females. It can present with various symptoms, including seizures, myoclonus, psychosis, hallucinations, and mood disturbances. Hypochondriacal delusion is an unusual clinical presentation of this disorder. The authors report a case of HE in a male patient whose clinical presentation was dominated by hypochondriacal delusion. The absence of response to antipsychotics, high serum antithyroid peroxidase antibodiesof about 199 UI/ml, the normality of magnetic resonance imaging, and improvement with corticosteroids confirmed the diagnosis. This neuroendocrine disorder is often misdiagnosed and it represents a diagnostic challenge for clinicians. It should be considered in patients presenting a refractory or an atypical neuropsychiatric disorder and having a family history of autoimmune disease.

Thyroid gland and brain: Enigma of Hashimoto's encephalopathy

The versatile clinical manifestations of the Hashimoto's chronic autoimmune thyroiditis often include psycho-neurological disorders. Although hypothyroidism disturbs significantly the ontogenesis and functions of central nervous system, causing in severe cases of myxedema profound impairment of cognitive abilities and even psychosis, the behavioral, motor and other psychoneurological disorders accompany euthyroid and slightly hypothyroid cases and periods of Hashimoto's disease as well, thus constituting the picture of so called "Hashimoto's encephalopathy". The entity, although discussed and explored for more than 50 years since its initial descriptions, remains an enigma of thyroidology and psychiatry, because its etiology and pathogenesis are obscure. The paper describes the development of current views on the role of thyroid in ontogeny and functions of brain, as well as classical and newest ideas on the etiology and pathogenesis of Hashimot's encephalopathy. The synopsis of the world case reports and research literature on this disorder is added with authors' own results obtained by study of 17 cases of Hashimoto's thyroiditis with schizophrenia-like clinical manifestations. The relation of the disease to adjuvant-like etiological factors is discussed. Three major mechanistic concepts of Hashimoto's encephalopathy are detailed, namely cerebral vasculitis theory, hormone dysregulation theory and concept, explaining the disease via direct action of the autoantibodies against various thyroid (thyroperoxidase, thyroglobulin, and TSH-receptor) and several extrathyroid antigens (alpha-enolase and other enzymes, gangliosides and MOG-protein, onconeuronal antigens) - all of them expressed in the brain. The article demonstrates that all above mentioned concepts intermingle and prone to unification, suggesting the unified scheme of pathogenesis for the Hashimoto's encephalopathy. The clinical manifestations, criteria, forms, course, treatment and prognosis of Hashimoto's encephalopathy and its comorbidity to other diseases - are also discussed in brief. The relation between Hashimoto's encephalopathy and non-vasculitis autoimmune encephalomyelitides of paraneoplastic and non-paraneoplastic origin is emphasized [1 figure, bibliography - 200 references].

Psychiatric Presentations Heralding Hashimoto's Encephalopathy: A Systematic Review and Analysis of Cases Reported in Literature

Hashimoto's encephalopathy (HE) may often present initially with psychiatric symptoms. These presentations are often variable in clinical aspects, and there has been no systematic analysis of the numerous psychiatric presentations heralding an eventual diagnosis of HE which will guide clinicians to make a correct diagnosis of HE. This systematic review was done to analyze the demographic characteristics, symptom typology, and clinical and treatment variables associated with such forerunner presentations. Electronic databases such as PubMed, ScienceDirect, and Google Scholar databases were searched to identify potential case reports that described initial psychiatric presentations of HE in English language peer-reviewed journals. The generated articles were evaluated and relevant data were extracted using a structured tool. We identified a total of forty articles that described 46 cases. More than half of the total samples (54.4%) were above the age of 50 years at presentation. The most common psychiatric diagnosis heralding HE was acute psychosis (26.1%) followed by depressive disorders (23.9%). Dementia (10.9%) and schizophrenia (2.2%) were uncommon presentations. Antithyroid peroxidase antibodies were elevated in all patients but not antithyroglobulin antibodies. Preexisting hypothyroidism was absent in majority of cases (60.9%). Steroid doses initiated were 500-1000 mg of intravenous methylprednisolone for majority (52.1%) of patients while oral steroid maintenance was required for a significant minority (39.1%). Psychiatric manifestations of HE may be heterogeneous and require a high index of clinical suspicion, especially in older adults. A range of clinical and treatment variables may assist clinicians in making a faster diagnosis and instituting prompt and effective management.

Spontaneous intracranial hypotension in Hashimoto's thyroiditis: A case report

RATIONALE

Autoimmune thyroid diseases (ATDs) seldom affect intracranial pressure. Here, we describe a case of spontaneous intracranial hypotension (SIH) related to Hashimoto's thyroiditis (HT), which has never been previously published.

PATIENT CONCERNS

A 54-year-old woman was admitted to our hospital due to sudden-onset postural headache, neck pain stiffness, visual blurring, nausea and vomiting. The headache was aggravated when the patient sat or stood up yet rapidly resolved within 1 minute after recumbency.

DIAGNOSIS

The patient had a grade 1a diffusely palpable thyroid gland and the laboratory report revealed elevated titers of anti-thyroid antibodies, a diagnosis of HT was established. Gadolinium-enhanced magnetic resonance imaging exhibited dilatation of the venous sinuses, obvious diffuse pachymeningeal enhancement, and narrowing of the ventricular system, combined with the lumbar puncture pressure was 60 mmH20 in the lateral recumbent position, and a diagnosis of SIH was eatablished.

INTERVENTIONS

The patient was placed on strict bed rest and hydrated for 15 days.

OUTCOMES

The headache was gradually relieved, a follow-up at 1 month after discharge revealed that the patient could stand and function normally.

LESSONS

SIH can be related to ATD.

Rare case of Hashimoto’s encephalitis mimicking grief reaction

A 46-year-old woman was admitted with tonic-clonic seizures. She was noticed to be withdrawn and low in mood for few months. She had reduced level of consciousness with hyper-reflexia and myoclonus. Metabolic, vasculitic, autoimmune, paraneoplastic and septic screen were normal. Lumbar puncture showed raised protein in the cerebrospinal fluid but the cytology, bacterial and viral screens were negative. A CT of the head revealed global brain swelling consistent with encephalitis which was empirically treated with antibiotics and antiviral therapy. Despite this she continued to have altered sensorium. She had moderately raised titres of antithyroid peroxidise antibodies suggestive of an underlying diagnosis of Hashimoto’s encephalitis. She displayed a significant improvement in her cognitive functions with high-dose steroids which was further in keeping with this rare diagnosis.

Hashimoto encephalopathy: literature review

Hashimoto encephalopathy (HE) presents as an encephalopathy without central nervous system infection or tumor. HE is associated with autoimmune thyroiditis and is thus considered to be an autoimmune disorder. The prevalence of HE is low, but death and status epilepticus have been reported. HE manifests with a wide range of symptoms that include behavioral changes and confusion. Elevated thyroid antibodies are present in the majority of cases and are required for the diagnosis of HE. Normal brain MRI findings are found in the majority of patients diagnosed with HE. The most consistent CSF abnormality noted in HE patients is the presence of elevated protein. Most HE patients respond well to steroid therapy. Clinical improvements are also observed with IV immunoglobulin and plasmapheresis. In conclusion, it is now generally accepted that the diagnosis of HE must include encephalopathy characterized by cognitive impairment associated with psychiatric features, such as hallucinations, delusions, and paranoia. Autoimmune encephalitis and prion disease should be considered in the differential diagnosis due to the similarity of the clinical features of these conditions to those of HE.

Risks and Benefits of Rituximab in the Treatment of Hashimoto Encephalopathy in Children: Two Case Reports and a Mini Review

Hashimoto encephalopathy is a rare condition, characterized by the association of encephalopathy with a variety of neurological symptoms and autoantibodies to the thyroid gland. Its etiology is unknown, and symptoms are usually treated with immune suppressive therapy, e.g., high doses of corticosteroids.

METHODS AND RESULTS

Here, we report the long-term outcome in two steroid-refractory adolescents with Hashimoto encephalopathy who were treated with rituximab, a monoclonal antibody directed against CD20. In addition, we reviewed the literature regarding treatment strategies in Hashimoto encephalopathy.

CONCLUSIONS

Anti-B-cell therapy can be of value in the treatment of Hashimoto encephalopathy, especially in steroid refractory cases, but side effects due to low levels of immunoglobulins warrant careful monitoring.

Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT): Characteristics, treatment and outcome in 251 cases from the literature

BACKGROUND

Steroid-responsive encephalopathy and associated autoimmune thyroiditis (SREAT) is characterized by encephalopathy and the presence of antithyroid antibodies. We describe the clinical presentation, outcome and treatments for SREAT by a systematic review of the literature.

METHODS

MEDLINE via PubMed, Web of Science and the Cochrane Library were searched for articles published until 2015. Inclusion criteria were unexplained encephalopathy with antithyroid antibodies.

RESULTS

We found reports of 251 patients (median age 52years [range 18-86], 73% females, 80 [32%] with preexisting thyroiditis). Patients presented encephalitis signs with convulsions (n=117; 47%), confusion (n=115, 46%), speech disorder (n=91, 37%), memory impairment (n=107, 43%), gait disturbance (n=67, 27%) and persecutory delusions (n=61, 25%). Twenty-eight patients (11%) presented progressive memory impairment and 26 (10%) isolated psychiatric disorders. In serum, 34% of patients were positive for anti-thyroid peroxidase (TPO) antibodies, 7% for anti-thyroglobulin (TG) antibodies, and 69% both. Thyroid-stimulating hormone levels were usually normal, at 2 UI/ml [0.001-205]. Cerebrospinal fluid from 10/53 patients (19%) was positive for anti-TPO antibodies, 2/53 (4%) anti-TG antibodies and 28 (53%) both. Electroencephalography findings were abnormal for 82% of patients, showing diffuse slowing consistent with encephalopathy (70%) or epileptic activity (14%). The first-line treatment was steroids in 193 patients and other immunosuppressive drugs in 10 cases. At a median follow-up of 12months [range 0.2-110], 91% of patients showed complete or partial neurological response, with anti-TPO and -TG antibody titers at 347 UI/ml [0-825,000] and 110 UI/ml [0-50,892], respectively. During follow-up, 40 patients (16%) experienced at least one relapse. Relapse was more frequent in patients with initial coma (26% vs 13%, p=0.08).

CONCLUSION

The diagnosis of SREAT should be suspected in case of encephalopathy without obvious cause, to quickly start corticosteroid treatment. The exact modalities of treatment must be defined.

Endocrine disorders and the neurologic manifestations

The nervous system and the endocrine system are closely interrelated and both involved intimately in maintaining homeostasis. Endocrine dysfunctions may lead to various neurologic manifestations such as headache, myopathy, and acute encephalopathy including coma. It is important to recognize the neurologic signs and symptoms caused by the endocrine disorders while managing endocrine disorders. This article provides an overview of the neurologic manifestations found in various endocrine disorders that affect pediatric patients. It is valuable to think about 'endocrine disorder' as a cause of the neurologic manifestations. Early diagnosis and treatment of hormonal imbalance can rapidly relieve the neurologic symptoms. Better understanding of the interaction between the endocrine system and the nervous system, combined with the knowledge about the pathophysiology of the neurologic manifestations presented in the endocrine disorders might allow earlier diagnosis and better treatment of the endocrine disorders.