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Sun QM, Zhang S, Xu YH, Ma J, Zhang YT, Zhang XY. Depression severity partially mediates the association between thyroid function and psychotic symptoms in first-episode, drug-naive major depressive disorder patients with comorbid anxiety at different ages of onset. J Affect Disord 2023; 339:342-347. [PMID: 37437726 DOI: 10.1016/j.jad.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 06/06/2023] [Accepted: 07/08/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Anxiety and psychotic symptoms are common in patients with major depressive disorder (MDD), with a strong association with thyroid function. Age of onset contributes to the heterogeneity of MDD patients. This study aimed to assess the prevalence of psychotic symptoms in MDD patients with comorbid anxiety and to explore the relationship between thyroid function and psychotic symptoms by ages of onset. METHODS A total of 894 first-episode, drug-naïve Chinese Han MDD patients with comorbid anxiety were recruited. Thyroid function and psychometric measures including Hamilton Anxiety Scale, Hamilton Depression Scale, and Positive and Negative Syndrome Scale were evaluated. Patients were divided into early adulthood onset (EAO, < 45 years old) and mid-adulthood onset (MAO, ≥ 45 years old) groups. RESULTS The MAO subgroup had a higher prevalence of psychotic symptoms compared to EAO subgroup. TSH and TPOAb levels were positively correlated with psychotic symptoms severity, with a more pronounced effect in MAO subgroup. Furthermore, MDD severity partially mediated the effects of TPOAb and TSH levels on psychotic symptoms in both subgroups. LIMITATIONS A causal relationship could not be demonstrated with this cross-sectional study, and the results should be limited to first-episode, drug-naïve MDD patients without considering more potential confounders. Moreover, the male-to-female ratio imbalance is present. CONCLUSIONS Our results indicated that age of onset moderated the association between thyroid function and psychotic symptom, and depression severity partially mediated the effects of thyroid function on psychotic symptoms, suggesting thyroid function may serve as a biomarker of psychotic symptoms in MDD patients with anxiety.
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Affiliation(s)
- Qi-Meng Sun
- The Second Affiliated Hospital of Xinxiang Medical University, Henan Mental Hospital, Xinxiang, China
| | - Sen Zhang
- The Second Affiliated Hospital of Xinxiang Medical University, Henan Mental Hospital, Xinxiang, China
| | - Ya-Hui Xu
- The Second Affiliated Hospital of Xinxiang Medical University, Henan Mental Hospital, Xinxiang, China
| | - Jun Ma
- Department of Psychiatry, Wuhan Mental Health Center, Wuhan, China
| | | | - Xiang-Yang Zhang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China.
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Dominguez LJ, Barbagallo M. Thyroid disorders. PATHY'S PRINCIPLES AND PRACTICE OF GERIATRIC MEDICINE 2022:1041-1058. [DOI: 10.1002/9781119484288.ch83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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3
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Kotkowska Z, Strzelecki D. Depression and Autoimmune Hypothyroidism—Their Relationship and the Effects of Treating Psychiatric and Thyroid Disorders on Changes in Clinical and Biochemical Parameters Including BDNF and Other Cytokines—A Systematic Review. Pharmaceuticals (Basel) 2022; 15:ph15040391. [PMID: 35455388 PMCID: PMC9025086 DOI: 10.3390/ph15040391] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 02/04/2023] Open
Abstract
Various autoimmune diseases, including autoimmune hypothyroidism (AHT), are associated with a higher risk of developing mood disorders throughout life. Depression is accompanied by the changes in the levels of inflammatory and trophic factors, including interleukins (IL-1beta, IL-2, IL-6), interferon alpha (IFN-alpha), tumor necrosis factor alpha (TNF-alpha), C-reactive protein (CRP), and brain derived neurotrophic factor (BDNF). Disclosure of the relationship between the coexistence of depression and AHT indicates that the pathomechanism of depression may be related to the changes in the immune system, it is also possible that both conditions may be caused by the same immune processes. The above hypothesis is indirectly supported by the observations that the treatment with both antidepressants and levothyroxine leads to a decrease in the levels of proinflammatory cytokines with an increase in BDNF concentrations, simultaneously correlating with an improvement in the clinical parameters. However, so far there are no long-term studies determining the causal relationship between depression, thyroid autoantibodies, and cytokine profile, which could bring us closer to understanding the interrelationships between them and facilitate the use of an adequate pharmacotherapy, not necessarily psychiatric. We consider the above issues to be insufficiently investigated but of great importance. This article is an overview of the available literature as well as an introduction to our research project.
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Fani L, Roa Dueñas O, Bos D, Vernooij MW, Klaver CCW, Ikram MK, Peeters RP, Ikram MA, Chaker L. Thyroid Status and Brain Circulation: The Rotterdam Study. J Clin Endocrinol Metab 2022; 107:e1293-e1302. [PMID: 34634119 PMCID: PMC8851919 DOI: 10.1210/clinem/dgab744] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Indexed: 11/28/2022]
Abstract
CONTEXT Whether thyroid dysfunction is related to altered brain circulation in the general population remains unknown. OBJECTIVE We determined the association of thyroid hormones with different markers of brain circulation within community-dwelling elderly people. METHODS This was a population-based study of 3 subcohorts of the Rotterdam Study, starting in 1989, 2000, and 2006. A total of 5142 participants (mean age, 63.8 years; 55.4% women), underwent venipuncture to measure serum thyroid-stimulating hormone (TSH) and free thyroxine (FT4). Between 2005 and 2015, all participants underwent phase-contrast brain magnetic resonance imaging to assess global brain perfusion (mL of blood flow/100 mL of brain/minute). Arteriolar retinal calibers were assessed using digitized images of stereoscopic fundus color transparencies in 3105 participants as markers of microcirculation. We investigated associations of TSH, FT4 with brain circulation measures using (non)linear regression models. RESULTS FT4 (in pmol/L) levels had an inverse U-shaped association with global brain perfusion, such that high and low levels of FT4 were associated with lower global brain perfusion than middle levels of FT4. The difference in global brain perfusion between high FT4 levels (25 pmol/L) and middle FT4 levels (FT4 = 15 pmol/L; P nonlinearity = .002) was up to -2.44 mL (95% CI -4.31; -0.56). Higher and lower levels of FT4, compared with middle FT4 levels, were associated with arteriolar retinal vessels (mean difference up to -2.46 µm, 95% CI -4.98; 0.05 for lower FT4). CONCLUSION These results suggest that thyroid dysfunction could lead to brain diseases such as stroke or dementia through suboptimal brain circulation that is potentially modifiable.
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Affiliation(s)
- Lana Fani
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Oscar Roa Dueñas
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Daniel Bos
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, The Netherlands
| | - Meike W Vernooij
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, The Netherlands
| | - Caroline C W Klaver
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Ophthalmology, Erasmus MC, the Netherlands
| | - M Kamran Ikram
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus MC, The Netherlands
| | - Robin P Peeters
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC, The Netherlands
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Layal Chaker
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC, The Netherlands
- Correspondence: Layal Chaker, MD, PhD, Department of Epidemiology, Erasmus MC University Medical Center, Dr. Molewaterplein 40, PO Box 2040, 3000CA Rotterdam, The Netherlands.
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Jurado-Flores M, Warda F, Mooradian A. Pathophysiology and Clinical Features of Neuropsychiatric Manifestations of Thyroid Disease. J Endocr Soc 2022; 6:bvab194. [PMID: 35059548 PMCID: PMC8765786 DOI: 10.1210/jendso/bvab194] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Indexed: 01/25/2023] Open
Abstract
Thyroid hormones (TH) have a cardinal role in the development of the central nervous system during embryogenesis and early infancy. However, the TH-responsive genes in the developing brain cease to respond to TH in adulthood. Nevertheless, thyroid dysfunction in adults is commonly associated with a host of cognitive and psychiatric problems. Cognitive decline, dysphoria, and depression are common manifestations of overt hypothyroidism while hyperthyroidism can cause agitation, acute psychosis, and apathy, especially in older people. Whereas levothyroxine treatment can reverse dementia in the setting of hypothyroidism, the effect of levothyroxine on depressive symptoms in subjects with subclinical hypothyroidism is controversial. The use of supraphysiologic doses of TH to treat depression refractory to antidepressant remains a viable therapeutic tool with the caveat that excessive doses of thyroid hormone to treat depression may have potentially damaging effects on other organ systems. The present communication describes the pathophysiology of neuropsychiatric manifestations of thyroid disease, including changes in neurotransmission, alterations in neuronal or glial cell gene expression, blood-brain barrier dysfunction, increased risk of cerebrovascular disease, and occasionally cerebral inflammatory disease in the context of autoimmune thyroid disease. Elucidating the molecular mechanisms of TH effect on cerebral tissue will help identify novel therapeutic targets for managing people with neuropsychiatric disorders.
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Affiliation(s)
- Marilu Jurado-Flores
- Division of Endocrinology, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Firas Warda
- Division of Endocrinology, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Arshag Mooradian
- Division of Endocrinology, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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Eslami-Amirabadi M, Sajjadi SA. The relation between thyroid dysregulation and impaired cognition/behaviour: An integrative review. J Neuroendocrinol 2021; 33:e12948. [PMID: 33655583 PMCID: PMC8087167 DOI: 10.1111/jne.12948] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/19/2020] [Accepted: 01/29/2021] [Indexed: 12/20/2022]
Abstract
Despite decades of research on the relation between thyroid diseases and cognition, the nature of this relationship remains elusive. An increasing prevalence of cognitive impairment and thyroid dysfunction has been consistently observed with ageing. Also, there appears to be an association between thyroid disorders and cognitive decline. Given the increasing global burden of dementia, elucidating the relationship between thyroid disorders as a potentially modifiable risk factor of cognitive impairment was the main goal of this review. We summarise the current literature examining the relationship between thyroid hormonal dysregulation and cognition or behaviour. We present the available imaging and pathological findings related to structural and functional brain changes related to thyroid hormonal dysregulation. We also propose potential mechanisms of interaction between thyroid hormones, autoantibodies and cognition/behaviour. Effects of gender, ethnicity and environmental factors are also briefly discussed. This review highlights the need for long-term prospective studies to capture the course of brain functional changes associated with the incidence and progression of thyroid dysregulations along with the confounding effects of non-modifiable risk factors such as gender and ethnicity. Moreover, double-blind controlled clinical trials are necessary to devise appropriate treatment plans to prevent cognitive consequences of over or undertreatment of thyroid disorders.
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7
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Ettleson MD, Bianco AC. Individualized Therapy for Hypothyroidism: Is T4 Enough for Everyone? J Clin Endocrinol Metab 2020; 105:dgaa430. [PMID: 32614450 PMCID: PMC7382053 DOI: 10.1210/clinem/dgaa430] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/29/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT It is well recognized that some hypothyroid patients on levothyroxine (LT4) remain symptomatic, but why patients are susceptible to this condition, why symptoms persist, and what is the role of combination therapy with LT4 and liothyronine (LT3), are questions that remain unclear. Here we explore evidence of abnormal thyroid hormone (TH) metabolism in LT4-treated patients, and offer a rationale for why some patients perceive LT4 therapy as a failure. EVIDENCE ACQUISITION This review is based on a collection of primary and review literature gathered from a PubMed search of "hypothyroidism," "levothyroxine," "liothyronine," and "desiccated thyroid extract," among other keywords. PubMed searches were supplemented by Google Scholar and the authors' prior knowledge of the subject. EVIDENCE SYNTHESIS In most LT4-treated patients, normalization of serum thyrotropin levels results in decreased serum T3/T4 ratio, with relatively lower serum T3 levels; in at least 15% of the cases, serum T3 levels are below normal. These changes can lead to a reduction in TH action, which would explain the slower rate of metabolism and elevated serum cholesterol levels. A small percentage of patients might also experience persistent symptoms of hypothyroidism, with impaired cognition and tiredness. We propose that such patients carry a key clinical factor, for example, specific genetic and/or immunologic makeup, that is well compensated while the thyroid function is normal but might become apparent when compounded with relatively lower serum T3 levels. CONCLUSIONS After excluding other explanations, physicians should openly discuss and consider therapy with LT4 and LT3 with those hypothyroid patients who have persistent symptoms or metabolic abnormalities despite normalization of serum thyrotropin level. New clinical trials focused on symptomatic patients, genetic makeup, and comorbidities, with the statistical power to identify differences between monotherapy and combination therapy, are needed.
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Affiliation(s)
- Matthew D Ettleson
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, USA
| | - Antonio C Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, USA
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8
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Clinical Response to Thyroidectomy in Three Cases of Refractory Hashimoto’s Encephalopathy—a Potential Therapy. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02476-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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9
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Bladowska J, Waliszewska-Prosół M, Ejma M, Sąsiadek M. The metabolic alterations within the normal appearing brain in patients with Hashimoto's thyroiditis are correlated with hormonal changes. Metab Brain Dis 2019; 34:53-60. [PMID: 30242734 PMCID: PMC6351519 DOI: 10.1007/s11011-018-0318-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 09/17/2018] [Indexed: 11/25/2022]
Abstract
Hashimoto's thyroiditis (HT) is the most common autoimmune disease in humans usually associated with subsequent hypothyroidism. The purpose of the study was to assess metabolic alterations within the normal appearing brain in subjects with HT using MR spectroscopy (MRS) and to correlate MRS measurements with hormonal concentrations. Fifty-five HT patients (mean age 43.5 yrs) and 30 healthy controls (mean age 42.5 yrs) were examined with the use of a 1.5 T MR scanner. There were no signs of central nervous system involvement in the studied group. The MRS examinations were performed using the single voxel method. The voxels were placed in the left parietal white matter (PWM) and the posterior cingulate gyrus (PCG). The NAA/Cr, Cho/Cr, and mI/Cr ratios were calculated. The correlations between metabolite ratios and hormonal concentrations (TSH, fT3, fT4) as well as anti-TG and anti-TPO levels were also assessed. We found significantly (p < 0.05) decreased NAA/Cr ratios in PCG and PWM in HT subjects compared to the control group. There were no other significant differences in metabolite ratios. We observed significant positive correlations between the NAA/Cr ratio in PCG as well as the PWM and fT3 level. There was also a significant negative correlation between the Cho/Cr ratio in the PCG and fT4 level. MRS could be a sensitive biomarker capable of depicting early cerebral metabolic disturbances associated with HT. Our findings may indicate the reduction of neuronal activity within the normal appearing brain in patients with HT as well as suggesting that there is a possible biological association between thyroid dysfunction and cerebral metabolic changes.
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Affiliation(s)
- Joanna Bladowska
- Department of General Radiology, Interventional Radiology and Neuroradiology, Wrocław Medical University, Wrocław, Poland
| | | | - Maria Ejma
- Department of Neurology, Wrocław Medical University, ul. Borowska 213, 50-556, Wrocław, Poland
| | - Marek Sąsiadek
- Department of General Radiology, Interventional Radiology and Neuroradiology, Wrocław Medical University, Wrocław, Poland
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Hrovat A, De Keuster T, Kooistra HS, Duchateau L, Oyama MA, Peremans K, Daminet S. Behavior in dogs with spontaneous hypothyroidism during treatment with levothyroxine. J Vet Intern Med 2018; 33:64-71. [PMID: 30499213 PMCID: PMC6335523 DOI: 10.1111/jvim.15342] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 10/15/2018] [Indexed: 11/27/2022] Open
Abstract
Background Thyroid hormone supplementation anecdotally has been described as a valid treatment option for dogs with aggression‐related problems. However, prospective, controlled, and blinded trials evaluating behavior and neurohormonal status in hypothyroid dogs during treatment with levothyroxine are lacking. Objective Levothyroxine supplementation will have a significant influence on the behavior and neurohormonal status of dogs with spontaneous hypothyroidism. Animals Twenty client‐owned dogs diagnosed with spontaneous hypothyroidism. Methods This prospective study was to evaluate the behavior of dogs, which was screened at initial presentation, and after 6 weeks, and 6 months of treatment with levothyroxine (starting dosage 10 μg/kg PO q12h) using the standardized Canine Behavioral Assessment and Research Questionnaire (C‐BARQ). At each time period, circulating serotonin and prolactin (PRL) concentrations were evaluated using a commercially validated ELISA kit and heterologous radioimmunoassay, respectively. Results After 6 weeks of thyroid hormone supplementation, C‐BARQ scores demonstrated a significant increase in activity of hypothyroid dogs (P < .01). No significant change in any of the behavioral signs was observed after 6 months of treatment. No significant difference in circulating concentrations of serotonin (P > .99 and P = .46) and PRL (P = .99 and P = .37) were noted between the 6‐week and 6‐month periods compared with baseline. Conclusions and Clinical Importance The results of this study indicate increased activity of hypothyroid dogs after 6 weeks of thyroid hormone supplementation. None of the hypothyroid dogs in this cohort showed a significant change in any of the evaluated behavioral signs and neurohormonal status after 6 months of thyroid hormone supplementation.
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Affiliation(s)
- Alenka Hrovat
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Tiny De Keuster
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Hans S Kooistra
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Luc Duchateau
- Biometrics Research Group, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Mark A Oyama
- Department of Clinical Studies-Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathelijne Peremans
- Department of Veterinary Medical Imaging and Small Animal Orthopedics, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Sylvie Daminet
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
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Siegmann EM, Müller HHO, Luecke C, Philipsen A, Kornhuber J, Grömer TW. Association of Depression and Anxiety Disorders With Autoimmune Thyroiditis: A Systematic Review and Meta-analysis. JAMA Psychiatry 2018; 75:577-584. [PMID: 29800939 PMCID: PMC6137529 DOI: 10.1001/jamapsychiatry.2018.0190] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE With a prevalence of 4% to 13% in the United States, autoimmune thyroiditis (AIT) is a major health problem. Besides somatic complications, patients with AIT can also experience psychiatric disorders. The extent of these organic psychiatric diseases in patients with AIT, however, is so far not commonly known. OBJECTIVE To provide meta-analytic data on the association of depression and anxiety with AIT. DATA SOURCES Google Scholar, the EBSCO Host databases, the Web of Knowledge, and PubMed were searched from inception through December 5, 2017. Articles identified were reviewed and reference lists were searched manually. STUDY SELECTION Case-control studies that reported the association between AIT and either depression or anxiety disorders or both were included. DATA EXTRACTION AND SYNTHESIS Data extraction was performed by multiple observers following the PRISMA guidelines. Two univariate random-effects meta-analyses were performed, and moderators were tested with Bonferroni-corrected meta-regression analysis. Heterogeneity was assessed with the I2 statistic. Sensitivity analyses tested the robustness of the results. Small study effects were assessed with funnel plots and the Egger test. MAIN OUTCOMES AND MEASURES The odds ratio of patients with AIT and depression compared with a healthy control group, as well as the odds ratio of patients with AIT and anxiety disorders compared with a healthy control group. RESULTS Nineteen studies comprising 21 independent samples were included, with a total of 36 174 participants (35 168 for depression and 34 094 for anxiety). Patients with AIT, Hashimoto thyroiditis, or subclinical or overt hypothyroidism had significantly higher scores on standardized depression instruments, with an odds ratio of 3.56 (95% CI, 2.14-5.94; I2 = 92.1%). For anxiety disorders, patients with AIT, Hashimoto thyroiditis, or subclinical or overt hypothyroidism had an odds ratio of 2.32 (95% CI, 1.40-3.85; I2 = 89.8%). Funnel plot asymmetry was detected for studies of depression. Study quality assessed with the Newcastle-Ottawa Scale for case-control studies (mean [SD] score: anxiety, 5.77 [1.17]; depression, 5.65 [1.14]; of a possible maximum score of 9) and proportion of females did not modulate the meta-analytic estimate, whereas mean age did. CONCLUSIONS AND RELEVANCE This meta-analysis establishes the association between AIT and depression and anxiety disorders. Patients with AIT exhibit an increased chance of developing symptoms of depression and anxiety or of receiving a diagnosis of depression and anxiety disorders. This finding has important implications for patients and could lead to the choice of early treatment-and not only psychotherapeutic treatment-of the organic disorder.
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Affiliation(s)
- Eva-Maria Siegmann
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany,Institute of Psychology, Otto-Friedrich-University, Bamberg, Germany
| | - Helge H. O. Müller
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Caroline Luecke
- Department of Psychiatry and Psychotherapy, Carl von Ossietzky University of Oldenburg, Bad Zwischenahn, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Teja Wolfgang Grömer
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Singh D, Dyer A, Gu S, McCarville P, Hess A, Akingbola O, El-Dahr J, Nelson S. An Unusual Cause of Frequent, Sudden, Transient, Unexplained Falls and New-Onset Status Epilepticus: Case Report and Mini-Review. Clin Pediatr (Phila) 2018; 57:173-179. [PMID: 28420263 DOI: 10.1177/0009922817698805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a 14-year old adolescent Caucasian female, who presented with frequent, sudden, transient, and unexplained falls leading to multiple serious injuries to her head and extremities requiring several visits to the emergency department. She was evaluated numerous times and imaging studies, echocardiogram, electrocardiogram, and electroencephalogram studies were all normal. She eventually presented to outside emergency department with dystonic posturing and status epilepticus and was transferred to our pediatric intensive care unit for further management. She was diagnosed with an uncommon, underrecognized and underdiagnosed condition. To our knowledge there is no such previous report in a pediatric patient.
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Affiliation(s)
- Dinesh Singh
- 1 Tulane University School of Medicine, New Orleans, LA, USA
| | - Alford Dyer
- 1 Tulane University School of Medicine, New Orleans, LA, USA
| | - Sherry Gu
- 1 Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Annie Hess
- 1 Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Jane El-Dahr
- 1 Tulane University School of Medicine, New Orleans, LA, USA
| | - Stephen Nelson
- 1 Tulane University School of Medicine, New Orleans, LA, USA
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Göbel A, Heldmann M, Sartorius A, Göttlich M, Dirk AL, Brabant G, Münte TF. Mild Thyrotoxicosis Leads to Brain Perfusion Changes: An Arterial Spin Labelling Study. J Neuroendocrinol 2017; 29. [PMID: 27859916 DOI: 10.1111/jne.12446] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 10/12/2016] [Accepted: 11/05/2016] [Indexed: 11/29/2022]
Abstract
Hypo- and hyperthyroidism have effects on brain structure and function, as well as cognitive processes, including memory. However, little is known about the influence of thyroid hormones on brain perfusion and the relationship of such perfusion changes with cognition. The present study aimed to demonstrate the effect of short-term experimental hyperthyroidism on brain perfusion in healthy volunteers and to assess whether perfusion changes, if present, are related to cognitive performance. It is known that an interaction exists between brain perfusion and cerebral oxygen consumption rate and it is considered that neural activation increases cerebral regional perfusion rate in brain areas associated with memory. Measuring cerebral blood flow may therefore represent a proxy for neural activity. Therefore, arterial spin labelling (ASL) measurements were conducted and later analysed to evaluate brain perfusion in 29 healthy men before and after ingesting thyroid hormones for 8 weeks. Psychological tests concerning memory were performed at the same time-points and the results were correlated with the imaging results. In the hyperthyroid condition, perfusion was increased in the posterior cerebellum in regions connected with cerebral networks associated with cognitive control and the visual cortex compared to the euthyroid condition. In addition, these perfusion changes were positively correlated with changes of performance in the German version of the Auditory Verbal Learning Task [AVLT, Verbaler Lern-und-Merkfähigkeits-Test (VLMT)]. Cerebellar perfusion and function therefore appears to be modulated by thyroid hormones, likely because the cerebellum hosts a high number of thyroid hormone receptors.
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Affiliation(s)
- A Göbel
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - M Heldmann
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Institute of Psychology II, University of Lübeck, Lübeck, Germany
| | - A Sartorius
- Central Institute of Mental Health, Mannheim, Germany
| | - M Göttlich
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - A-L Dirk
- Department of Internal Medicine I, University of Lübeck, Lübeck, Germany
| | - G Brabant
- Department of Internal Medicine I, University of Lübeck, Lübeck, Germany
| | - T F Münte
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Institute of Psychology II, University of Lübeck, Lübeck, Germany
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Bocchetta A, Traccis F, Mosca E, Serra A, Tamburini G, Loviselli A. Bipolar disorder and antithyroid antibodies: review and case series. Int J Bipolar Disord 2016; 4:5. [PMID: 26869176 PMCID: PMC4751106 DOI: 10.1186/s40345-016-0046-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 01/25/2016] [Indexed: 11/23/2022] Open
Abstract
Mood disorders and circulating thyroid antibodies are very prevalent in the population and their concomitant occurrence may be due to chance. However, thyroid antibodies have been repeatedly hypothesized to play a role in specific forms of mood disorders. Potentially related forms include treatment-refractory cases, severe or atypical depression, and depression at specific phases of a woman’s life (early gestation, postpartum depression, perimenopausal). With regard to bipolar disorder, studies of specific subgroups (rapid cycling, mixed, or depressive bipolar) have reported associations with thyroid antibodies. Offspring of bipolar subjects were found more vulnerable to develop thyroid antibodies independently from the vulnerability to develop psychiatric disorders. A twin study suggested thyroid antibodies among possible endophenotypes for bipolar disorder. Severe encephalopathies have been reported in association with Hashimoto’s thyroiditis. Cases with pure psychiatric presentation are being reported, the antithyroid antibodies being probably markers of some other autoimmune disorders affecting the brain. Vasculitis resulting in abnormalities in cortical perfusion is one of the possible mechanisms.
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Affiliation(s)
- Alberto Bocchetta
- Unit of Clinical Pharmacology, Section of Neurosciences, Department of Biomedical Sciences, "San Giovanni di Dio" Hospital, University of Cagliari, Via Ospedale 54, 09124, Cagliari, Italy.
| | - Francesco Traccis
- Unit of Clinical Pharmacology, Section of Neurosciences, Department of Biomedical Sciences, "San Giovanni di Dio" Hospital, University of Cagliari, Via Ospedale 54, 09124, Cagliari, Italy.
| | - Enrica Mosca
- Unit of Clinical Pharmacology, Section of Neurosciences, Department of Biomedical Sciences, "San Giovanni di Dio" Hospital, University of Cagliari, Via Ospedale 54, 09124, Cagliari, Italy.
| | - Alessandra Serra
- Department of Medical Sciences "Mario Aresu", University of Cagliari, Cagliari, Italy.
| | - Giorgio Tamburini
- Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Cagliari, Italy.
| | - Andrea Loviselli
- Department of Medical Sciences "Mario Aresu", University of Cagliari, Cagliari, Italy.
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15
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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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16
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Cognitive and affective dysfunctions in autoimmune thyroiditis. Brain Behav Immun 2014; 41:261-6. [PMID: 24685840 DOI: 10.1016/j.bbi.2014.03.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 03/07/2014] [Accepted: 03/14/2014] [Indexed: 11/21/2022] Open
Abstract
Hashimoto's thyroiditis (HT) is the most frequent cause of hypothyroidism in areas with sufficient iodine intake. While the impact of thyroid function on mood and cognition is well known, only in the recent years, an increasing number of studies report on the association of HT with cognitive and affective disturbances also in the euthyroid state. Recent imaging studies have shown that these impairments are accompanied by altered brain perfusion, in particular, in the frontal lobe and a reduced gray matter density in the left inferior gyrus frontalis. Brain function abnormalities in euthyroid patients with HT may be subtle and only detected by specific testing or even severe as it is the case in the rare neuropsychiatric disorder Hashimoto's encephalopathy (HE). The good response to glucocorticoids in patients with HE indicates an autoimmune origin. In line with this, the cognitive deficits and the high psycho-social burden in euthyroid HT patients without apparent signs of encephalopathy appear to be associated with anti-thyroid peroxidase auto-antibody (TPO Abs) levels. Though in vitro studies showing binding of TPO Abs to human cerebellar astrocytes point to a potential direct role of TPO Abs in the pathogenesis of brain abnormalities in HT patients, TPO Abs may function only as a marker of an autoimmune disorder of the central nervous system. In line with this, anti-central nervous system auto-antibodies (CNS Abs) which are markedly increased in patients with HT disturb myelinogenesis in vitro and, therefore, may impair myelin sheath integrity. In addition, in HT patients, production of monocyte- and T-lymphocyte-derived cytokines is also markedly increased which may negatively affect multiple neurotransmitters and, consequently, diverse brain neurocircuits.
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Cho HJ, Kim SS, Sung SM, Jung DS. Impact of Thyroid Autoantibodies on Functional Outcome in Patients with Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2014; 23:1915-20. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 01/29/2014] [Accepted: 02/05/2014] [Indexed: 10/25/2022] Open
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18
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Structural and functional MRI study of the brain, cognition and mood in long-term adequately treated Hashimoto's thyroiditis. Psychoneuroendocrinology 2014; 42:188-98. [PMID: 24636515 DOI: 10.1016/j.psyneuen.2014.01.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 01/09/2014] [Accepted: 01/22/2014] [Indexed: 11/24/2022]
Abstract
The current study investigated neuropsychological and underlying structural and functional brain alterations in long-term adequately treated patients with Hashimoto's thyroiditis in order to examine much discussed residual complaints in patients in relation to possible long-term neural alterations with a specific interest in the underlying autoimmune process. Eighteen patients with treated hypothyroidism due to Hashimoto's thyroiditis (mean age 32, range 18-54 years; two males; mean treatment duration 4.4 years) and 18 healthy matched control subjects underwent 3-Tesla magnetic resonance imaging (MRI). Voxel-based morphometry was used to investigate grey matter density, resting-state functional MRI to analyse the brain connectivity of areas known to be altered in hypothyroidism and event-related functional MRI to examine brain activity during associative memory encoding. Neuropsychological assessment included memory, working memory, psychomotor speed and attention. We previously reported subclinically reduced mood in this study population and investigated its neural correlates here. Thyroid stimulating hormone, free triiodthyronine, free thyroxine and thyroid peroxidase antibodies were measured in serum. We did not find cognitive deficits or alterations in grey matter density, functional connectivity or associative memory-related brain activity in comparison to the control group and cognition was unrelated to thyroid serum measures in the patient group. Thyroid peroxidase antibodies in the patient group correlated with increased grey matter density in right amygdala and enhanced connectivity between subcallosal and parahippocampal areas. Treatment duration was associated with brain structure in frontal and occipital cortex and connectivity between left amygdala and frontal cortex. Mood correlated with brain areas associated with distinct functional networks, but not with those most prominently affected in depression. In conclusion, no cognitive or neural alterations were detected in this young and otherwise healthy cohort of patients in comparison to a healthy control group and current mood status could not be related to depression-related networks. However, autoimmune activity and treatment duration showed a relationship with depression and hypothyroidism-related brain structure and function. They are thus promising factors to further investigate residual complaints despite biochemically adequate treatment in patients with Hashimoto's thyroiditis. Given the small sample size, all findings require replication.
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Pilhatsch M, Schlagenhauf F, Silverman D, Berman S, London ED, Martinez D, Whybrow PC, Bauer M. Antibodies in autoimmune thyroiditis affect glucose metabolism of anterior cingulate. Brain Behav Immun 2014; 37:73-7. [PMID: 24365060 DOI: 10.1016/j.bbi.2013.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 12/05/2013] [Accepted: 12/16/2013] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Hypothyroidism induced by an autoimmune process is associated with neuropsychiatric symptoms and metabolic abnormalities in the brain. The aim of this study was to examine the relationship between autoimmune thyroiditis and regional brain function in hypothyroid patients. METHODS Cerebral glucose metabolism, as an index of brain function, was assessed in regional whole-brain analyses using positron emission tomography (PET) and [18F]fluorodeoxyglucose in thirteen hypothyroid patients with autoimmune thyroiditis suffering from neuropsychiatric symptoms. The primary biological measures were radioactivity in pre-selected brain regions, relative to whole-brain radioactivity, as a surrogate index of glucose metabolism, and serum levels of thyroglobulin (TG) and thyroid peroxidase (TPO) antibodies as endocrine markers of autoimmune thyroiditis. RESULTS Serum levels of anti-TG antibodies in hypothyroid patients were significantly correlated with glucose metabolism in the perigenual anterior cingulate cortex, a brain region previously shown to regulate affect and emotional homeostasis. CONCLUSION Thyroid autoimmune processes may play an important role in the still poorly defined pathogenic correlates of disturbed function in brain regions critically involved in emotional processing in hypothyroid conditions.
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Affiliation(s)
- M Pilhatsch
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - F Schlagenhauf
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - D Silverman
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - S Berman
- Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - E D London
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - D Martinez
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - P C Whybrow
- Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - M Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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20
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Leyhe T, Ethofer T, Bretscher J, Künle A, Säuberlich AL, Klein R, Gallwitz B, Häring HU, Fallgatter A, Klingberg S, Saur R, Müssig K. Low performance in attention testing is associated with reduced grey matter density of the left inferior frontal gyrus in euthyroid patients with Hashimoto's thyroiditis. Brain Behav Immun 2013; 27:33-7. [PMID: 23010451 DOI: 10.1016/j.bbi.2012.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 09/04/2012] [Accepted: 09/14/2012] [Indexed: 10/27/2022] Open
Abstract
Hashimoto's thyroiditis (HT) can casually co-occur with an encephalopathy associated with autoimmune thyroid disease. Recently we found an increased occurrence of weaknesses in sustained attention and response inhibition in a subgroup of euthyroid patients with HT as obtained by the d2 attention test. Previous studies in healthy subjects and patients with brain lesions demonstrated a pivotal role for the left inferior frontal gyrus (LIFG) in these skills. Therefore, we studied the association between the performance in the d2 test and grey matter (GM) density of the LIFG in 13 euthyroid patients with HT compared to a control group of 12 euthyroid patients with other thyroid diseases. A significant correlation between GM density and d2 test total score was detected for the opercular part of the LIFG in patients with HT (p<0.001), but not in the control group (p=0.94). Regression in patients with HT was significantly stronger than in the control group (p=0.02). Moreover, GM density was significantly reduced when comparing HT patients with control patients that scored in the lower third during d2 attention testing (p<0.05). It can be concluded that in HT performance in the d2 test correlated with GM density of the LIFG. Particularly low achievement was associated with reduced GM density of this brain region suggesting an influence of autoimmune processes on the frontal cortex in this disease. This could be due to not yet known antibodies affecting brain morphology or an influence of thyroid antibodies themselves.
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Affiliation(s)
- Thomas Leyhe
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Germany.
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21
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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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22
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Müssig K, Künle A, Säuberlich AL, Weinert C, Ethofer T, Saur R, Klein R, Häring HU, Klingberg S, Gallwitz B, Leyhe T. Thyroid peroxidase antibody positivity is associated with symptomatic distress in patients with Hashimoto's thyroiditis. Brain Behav Immun 2012; 26:559-63. [PMID: 22285302 DOI: 10.1016/j.bbi.2012.01.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 12/25/2011] [Accepted: 01/10/2012] [Indexed: 11/28/2022] Open
Abstract
Previous studies suggest impairments of physical, mental, and psychic well-being in patients with Hashimoto's thyroiditis (HT), but these impairments have been shown to be independent of thyroid dysfunction. In 64 euthyroid patients with HT, symptomatic distress was assessed with the Symptom Checklist-90-Revised (SCL-90-R), a 90-item multidimensional self-report symptom inventory using a 5-point rating scale. In a subgroup of patients, endocrine testing 3 years prior to the current investigation was available. Anti-thyroid peroxidase antibodies (TPO-Abs) were associated with the three SCL-90-R global indices Global Severity Index (GSI), Positive Symptom Distress Index (PSDI), and Positive Symptom Total (PST) as well as with somatization and obsessive-compulsive symptoms after adjustment for age, gender, and thyroid function as assessed by TSH levels (all p<0.05). HT patients positive for TPO-Abs showed poorer results in the three SCL-90-R global indices as well as in the three domains: somatization, obsessive-compulsive symptoms, and depression (all p≤0.02), though the aforementioned associations did not withstand sequential Bonferroni correction for multiple testing. In contrast, TPO-Abs positivity, defined as TPO-Abs >100 IU/l, significantly predicted poorer psychosocial well-being in all of the three SCL-90-R global indices after three years, even after correction (all p≤0.02). In conclusion, high TPO-Abs are associated with poor physical and psychological well-being and appear to predict future health perception in HT patients.
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Affiliation(s)
- Karsten Müssig
- Division of Endocrinology, Diabetes, Angiology, Nephrology and Clinical Chemistry, Department of Internal Medicine, University of Tübingen, Otfried-Müller-Str. 10, 72076 Tübingen, Germany.
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23
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Dominguez LJ, Belvedere M, Barbagallo M. Thyroid Disorders. PATHY'S PRINCIPLES AND PRACTICE OF GERIATRIC MEDICINE 2012:1183-1197. [DOI: 10.1002/9781119952930.ch98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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24
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Abstract
Kinnier Wilson coined the term metabolic encephalopathy to describe a clinical state of global cerebral dysfunction induced by systemic stress that can vary in clinical presentation from mild executive dysfunction to deep coma with decerebrate posturing; the causes are numerous. Some mechanisms by which cerebral dysfunction occurs in metabolic encephalopathies include focal or global cerebral edema, alterations in transmitter function, the accumulation of uncleared toxic metabolites, postcapillary venule vasogenic edema, and energy failure. This article focuses on common causes of metabolic encephalopathy, and reviews common causes, clinical presentations and, where relevant, management.
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Affiliation(s)
- Michael J Angel
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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25
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Payer J, Petrovic T, Lisy L, Langer P. Hashimoto encephalopathy: a rare intricate syndrome. Int J Endocrinol Metab 2012; 10:506-14. [PMID: 23843812 PMCID: PMC3693614 DOI: 10.5812/ijem.4174] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 02/06/2012] [Accepted: 02/29/2012] [Indexed: 01/18/2023] Open
Abstract
Recently, several patients have been reported with various signs of encephalopathy and high thyroid antibody levels together with good responsiveness to glucocorticoid therapy. Despite the various clinical presentations, these cases have been termed "Hashimoto encephalopathy" (HE). Although all of the pathogenic components have not yet been clearly elucidated, it is believed that brain vasculitis and autoimmunity directed against common brain-thyroid antigens represent the most likely etiologic pathway. The most common clinical signs include unexplained or epilepsy-like seizures resistant to anti-convulsive treatment, confusion, headaches, hallucinations, stroke-like episodes, coma, impairment of cognitive function, behavioral and mood disturbance, focal neurological deficits, disturbance of consciousness, ataxia, and presenile dementia, together with the presence of high thyroid antibody levels, especially against thyroperoxidase (TPOab). In most cases, the thyroid function is normal or decreased; the thyroid function is rarely increased. The examination of the cerebrospinal fluid, EEG, MRI, SPECT, and neuropsychological examinations are primarily used as diagnostic tools. Most cases showed neural symptoms for months before the acute onset; in some cases, a dramatic acute onset was described. Once the diagnosis is made, corticosteroid treatment usually provides a dramatic recovery. The authors also present a short review of literary cases reported in last decade.
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Affiliation(s)
- Juraj Payer
- Clinic of Internal Medicine, Faculty of Medicine, Comenius University, Faculty Hospital Ruzinov, Bratislava, Slovakia
- Corresponding author: Juraj Payer, Clinic of Internal Medicine, Faculty of Medicine, Comenius University, Faculty Hospital Ruzinov, Bratislava, Slovakia. Tel.: +421-248234108, Fax: +421-248234110, E-mail:
| | - Tomas Petrovic
- Clinic of Internal Medicine, Faculty of Medicine, Comenius University, Faculty Hospital Ruzinov, Bratislava, Slovakia
| | - Lubomir Lisy
- Clinic of Neurology, Slovak Medical University, Bratislava, Slovakia
| | - Pavel Langer
- Institute of Experimental Endocrinology, Slovak Acadeamy of Sciences, Bratislava, Slovakia
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26
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Madeira N, Santos T. Depression: An unrecognized presentation of hyperthyroidism in old age. Eur Geriatr Med 2011. [DOI: 10.1016/j.eurger.2011.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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27
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Hardoy MC, Cadeddu M, Serra A, Moro MF, Mura G, Mellino G, Bhat KM, Altoé G, Usai P, Piga M, Carta MG. A pattern of cerebral perfusion anomalies between major depressive disorder and Hashimoto thyroiditis. BMC Psychiatry 2011; 11:148. [PMID: 21910915 PMCID: PMC3184264 DOI: 10.1186/1471-244x-11-148] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 09/13/2011] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND This study aims to evaluate relationship between three different clinical conditions: Major Depressive Disorders (MDD), Hashimoto Thyroiditis (HT) and reduction in regional Cerebral Blood Flow (rCBF) in order to explore the possibility that patients with HT and MDD have specific pattern(s) of cerebral perfusion. DESIGN Analysis of data derived from two separate data banks. SAMPLE 54 subjects, 32 with HT (29 women, mean age 38.8 ± 13.9); 22 without HT (19 women, mean age 36.5 ± 12.25). ASSESSMENT Psychiatric diagnosis was carried out by Simplified Composite International Diagnostic Interview (CIDIS) using DSM-IV categories; cerebral perfusion was measured by (99 m)Tc-ECD SPECT. Statistical analysis was done through logistic regression. RESULTS MDD appears to be associated with left frontal hypoperfusion, left temporal hypoperfusion, diffuse hypoperfusion and parietal perfusion asymmetry. A statistically significant association between parietal perfusion asymmetry and MDD was found only in the HT group. CONCLUSION In HT, MDD is characterized by a parietal flow asymmetry. However, the specificity of rCBF in MDD with HT should be confirmed in a control sample with consideration for other health conditions. Moreover, this should be investigated with a longitudinally designed study in order to determine a possible pathogenic cause. Future studies with a much larger sample size should clarify whether a particular perfusion pattern is associated with a specific course or symptom cluster of MDD.
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Affiliation(s)
| | | | - Alessandra Serra
- Department of Internal Medicine, University of Cagliari, Cagliari, Italy
| | | | - Gioia Mura
- Department of Public Health, University of Cagliari, Cagliari, Italy
| | - Gisa Mellino
- Department of Public Health, University of Cagliari, Cagliari, Italy
| | - Krishna M Bhat
- Department of Neuroscience & Cell Biology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Gianmarco Altoé
- Department of Psychology, University of Cagliari, Cagliari, Italy
| | - Paolo Usai
- Department of Internal Medicine, University of Cagliari, Cagliari, Italy
| | - Mario Piga
- Department of Internal Medicine, University of Cagliari, Cagliari, Italy
| | - Mauro G Carta
- Department of Public Health, University of Cagliari, Cagliari, Italy
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28
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Chakrabarti S. Thyroid functions and bipolar affective disorder. J Thyroid Res 2011; 2011:306367. [PMID: 21808723 PMCID: PMC3144691 DOI: 10.4061/2011/306367] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 04/23/2011] [Accepted: 05/29/2011] [Indexed: 02/05/2023] Open
Abstract
Accumulating evidence suggests that hypothalamo-pituitary-thyroid (HPT) axis dysfunction is relevant to the pathophysiology and clinical course of bipolar affective disorder. Hypothyroidism, either overt or more commonly subclinical, appears to the commonest abnormality found in bipolar disorder. The prevalence of thyroid dysfunction is also likely to be greater among patients with rapid cycling and other refractory forms of the disorder. Lithium-treatment has potent antithyroid effects and can induce hypothyroidism or exacerbate a preexisting hypothyroid state. Even minor perturbations of the HPT axis may affect the outcome of bipolar disorder, necessitating careful monitoring of thyroid functions of patients on treatment. Supplementation with high dose thyroxine can be considered in some patients with treatment-refractory bipolar disorder. Neurotransmitter, neuroimaging, and genetic studies have begun to provide clues, which could lead to an improved understanding of the thyroid-bipolar disorder connection, and more optimal ways of managing this potentially disabling condition.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
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29
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Moodley K, Botha J, Raidoo DM, Naidoo S. Immuno-localisation of anti-thyroid antibodies in adult human cerebral cortex. J Neurol Sci 2011; 302:114-7. [DOI: 10.1016/j.jns.2010.11.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 11/24/2010] [Accepted: 11/30/2010] [Indexed: 10/18/2022]
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30
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Angel MJ, Chen R, Bryan Young G. Metabolic encephalopathies. HANDBOOK OF CLINICAL NEUROLOGY 2010; 90:115-66. [PMID: 18631820 DOI: 10.1016/s0072-9752(07)01707-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Michael J Angel
- University of Toronto, Division of Neurology, Toronto Western Hospital, Toronto, Ontario, Canada.
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31
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Abstract
PURPOSE OF REVIEW To discuss the effects of thyroid dysfunction and thyroid autoimmunity on mental symptoms and disorders in patients with thyroid disease with reference to recent epidemiological, clinical, and genetic findings. RECENT FINDINGS During brain development, iodine deficiency, maternal thyroid dysfunction, and neonatal thyroid malformations together with genetic factors contribute to neurological deficit. Most adults with thyroid dysfunction will develop mental symptoms. In hyperthyroidism, adrenergic hyperactivity is a major cause of psychiatric symptoms, and beta-adrenergic antagonists are effective treatment. Most patients with severe hypothyroidism will also demonstrate mental symptoms; however, causality is not so evident as in hyperthyroidism. Polymorphism in deiodinase genes and in transporter genes appears to make an important contribution to the presentation of mental symptoms as well as to the outcome of treatment of hypothyroidism. A thyroid autoimmunity process may by itself contribute to mental symptoms in vulnerable patients. Data from epidemiological studies provide conflicting evidence as to associations between thyroid disorders and mental symptoms. SUMMARY In the adult brain, compared with the developing brain, brain-thyroid relationships are less apparent but still important. Adrenergic hyperactivity is a major cause of psychiatric symptoms in hyperthyroidism. Genetic factors contribute to the development and treatment outcome of mental disorder in hypothyroidism.
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32
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Tamagno G, Celik Y, Simó R, Dihné M, Kimura K, Gelosa G, Lee BI, Hommet C, Murialdo G. Encephalopathy associated with autoimmune thyroid disease in patients with Graves' disease: clinical manifestations, follow-up, and outcomes. BMC Neurol 2010; 10:27. [PMID: 20426819 PMCID: PMC2876143 DOI: 10.1186/1471-2377-10-27] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2009] [Accepted: 04/28/2010] [Indexed: 11/20/2022] Open
Abstract
Background The encephalopathy associated with autoimmune thyroid disease (EAATD) is characterized by neurological/psychiatric symptoms, high levels of anti-thyroid antibodies, increased cerebrospinal fluid protein concentration, non-specific electroencephalogram abnormalities, and responsiveness to the corticosteroid treatment in patients with an autoimmune thyroid disease. Almost all EAATD patients are affected by Hashimoto's thyroiditis (HT), although fourteen EAATD patients with Graves' disease (GD) have been also reported. Methods We have recorded and analyzed the clinical, biological, radiological, and electrophysiological findings and the data on the therapeutic management of all GD patients with EAATD reported so far as well as the clinical outcomes in those followed-up in the long term. Results Twelve of the fourteen patients with EAATD and GD were women. The majority of GD patients with EAATD presented with mild hyperthyroidism at EAATD onset or shortly before it. Active anti-thyroid autoimmunity was detected in all cases. Most of the patients dramatically responded to corticosteroids. The long term clinical outcome was benign but EAATD can relapse, especially at the time of corticosteroid dose tapering or withdrawal. GD and HT patients with EAATD present with a similar clinical, biological, radiological, and electrophysiological picture and require an unaffected EAATD management. Conclusions GD and HT equally represent the possible background condition for the development of EAATD, which should be considered in the differential diagnosis of all patients with encephalopathy of unknown origin and an autoimmune thyroid disease, regardless of the nature of the underlying autoimmune thyroid disease.
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Affiliation(s)
- Gianluca Tamagno
- Department of Endocrinology and Diabetes Mellitus, St Vincent's University Hospital, University College Dublin, Dublin, Ireland.
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Castro-Gago M, Gómez-Lado C, Maneiro-Freire M, Eirís-Puñal J, Bravo-Mata M. Hashimoto encephalopathy in a preschool girl. Pediatr Neurol 2010; 42:143-6. [PMID: 20117754 DOI: 10.1016/j.pediatrneurol.2009.09.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 08/05/2009] [Accepted: 09/18/2009] [Indexed: 01/18/2023]
Abstract
Hashimoto encephalopathy is a steroid-responsive encephalopathy associated with elevated blood concentrations of antithyroid antibodies. The patients are usually euthyroid or mildly hypothyroid. The clinical picture is pleomorphic, presenting with variable symptoms ranging from behavioral and cognitive changes, myoclonus, seizures, pyramidal tract dysfunction, involuntary movements, and cerebellar signs to psychosis and coma, with relapsing and progressive course. The diagnosis is often overlooked at presentation but is crucial, given that this is a treatable disease. Described here, with a literature review, is the youngest patient reported to date with Hashimoto encephalopathy.
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Affiliation(s)
- Manuel Castro-Gago
- Neuropediatric Service, Department of Pediatrics, University Hospital, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain.
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Müssig K, Leyhe T, Holzmüller S, Klein R, Weinert C, Saur R, Klingberg S, Häring HU, Gallwitz B. Increased prevalence of antibodies to central nervous system tissue and gangliosides in Hashimoto's thyroiditis compared to other thyroid illnesses. Psychoneuroendocrinology 2009; 34:1252-6. [PMID: 19375868 DOI: 10.1016/j.psyneuen.2009.03.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Revised: 03/12/2009] [Accepted: 03/14/2009] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous studies point to central nervous system (CNS) alterations in euthyroid patients with Hashimoto's thyroiditis (HT). The aim of the present study was to investigate the prevalence and clinical significance of antibodies (Abs) against CNS tissue and gangliosides in female patients with HT compared to patients with other non-autoimmune thyroid disorders, comprising diffuse or nodular goitre and thyroid surgery for goitre. METHODS 58 HT patients (mean age: 46+/-17 years) and 89 patients with other thyroid disorders (mean age: 51+/-15 years) were recruited consecutively from our endocrine outpatient clinic. Serum Abs against CNS tissue and gangliosides were determined using an enzyme-linked immunosorbent assay (ELISA). In a subgroup of 23 HT patients, neurocognitive function was studied using established neuropsychological tests. RESULTS In HT patients, the prevalence of serum anti-ganglioside-Abs and anti-CNS-Abs were significantly higher compared to patients with other thyroid disorders (p<0.05 and p<0.005, respectively). In both cases, the number of Ab-positive HT patients was twice that of Ab-positive controls. Reactivity of IgM-Abs to gangliosides and IgG-Abs to CNS tissue was significantly higher in HT patients than in controls (p<0.05 and p<0.01, respectively). However, prevalence and reactivity of Abs to gangliosides and CNS tissue were associated neither with the prevalence of depression nor with impairment of neurocognitive function in HT patients. CONCLUSION Ab reactivity towards CNS tissue and gangliosides is markedly enhanced in patients with HT as compared to patients with other thyroid disorders. Whether these Abs could be of prognostic value to evaluate the risk of future neurocognitive impairment has to be investigated in longitudinal studies.
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Affiliation(s)
- Karsten Müssig
- Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry, Department of Internal Medicine, University of Tübingen, Otfried-Müller-Str. 10, 72076 Tübingen, Germany.
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Hashimoto encephalopathy: Neurological and psychiatric perspective. ARCH BIOL SCI 2009. [DOI: 10.2298/abs0903383p] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Hashimoto encephalopathy (HE) is an autoimmune disease with neurological and neuropsychiatric manifestations and elevated titers of antithyroid antibodies in serum and cerebrospinal fluid. Patients are mostly women. Age varies from 8 to 86 years. Prevalence of HE is estimated to be 2.1/100,000. Neurological and/or psychiatric symptoms and signs constitute the clinical picture. The disease responds well to corticosteroid therapy, but sometimes other immunomodulatory therapies must be applied. Autoimmune mechanisms with antibodies against antigens in the brain cortex are suspected. The course of the disease can be acute, subacute, chronic, or relapsing/remitting. Some patients improve spontaneously, but a few died in spite of adequate therapy.
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Nanri K, Okita M, Takeguchi M, Taguchi T, Ishiko T, Saito H, Otsuka T, Mitoma H, Koizumi K. Intravenous immunoglobulin therapy for autoantibody-positive cerebellar ataxia. Intern Med 2009; 48:783-90. [PMID: 19443972 DOI: 10.2169/internalmedicine.48.1802] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE It has been reported that autoimmune cerebellar ataxias, such as anti-glutamic acid decarboxylase (GAD)-antibody-positive cerebellar ataxia and gluten ataxia, are treatable. Here, we examined the therapeutic efficacy of intravenous immunoglobulin (IVIg) on autoantibody-positive cerebellar ataxia. PATIENTS AND METHODS IVIg therapy was administered in seven autoantibody-positive cerebellar ataxia patients. Therapeutic efficacy was examined in terms of its effects on clinical symptoms and changes in brain perfusion using single photon emission computed tomography (SPECT). RESULTS Treatment was effective in four cerebellar cortical atrophy patients (two anti-GAD antibody-positive and two anti-gliadin antibody-positive) and in one anti-thyroid antibody-positive spinocerebellar ataxia type 3 (SCA3) patient, but not in two multiple system atrophy (MSA) patients. All four IVIg effective patients who underwent SPECT showed apparent increases in cerebellar perfusion. CONCLUSION If cerebellar ataxia with an autoimmune mechanism is suspected and radiological findings do not reveal MSA, it is worth considering immunotherapy including IVIg.
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Affiliation(s)
- Kazunori Nanri
- Department of Neurology, Tokyo Medical University Hachioji Medical Center, Tokyo.
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Leyhe T, Müssig K, Weinert C, Laske C, Häring HU, Saur R, Klingberg S, Gallwitz B. Increased occurrence of weaknesses in attention testing in patients with Hashimoto's thyroiditis compared to patients with other thyroid illnesses. Psychoneuroendocrinology 2008; 33:1432-6. [PMID: 18819753 DOI: 10.1016/j.psyneuen.2008.08.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Revised: 08/05/2008] [Accepted: 08/08/2008] [Indexed: 10/21/2022]
Abstract
Previous studies suggest disturbances of the central nervous system (CNS) in patients with Hashimoto's thyroiditis (HT), independently of thyroid function disorders. In the present prospective study, neuropsychological testing was performed for the first time in 26 euthyroid patients with HT compared to 25 euthyroid patients undergoing hormonal treatment for goitre or after thyroid surgery. We investigated executive function, attention, visual and verbal memory as well as acoustic working memory with established neuropsychological tests and detected no significant differences between the two groups. In addition, test results were expressed as z-score which is defined as the deviation of an individual's value from the mean value of a reference population, divided by the standard deviation of the reference population. Thereby, we found significantly more HT patients with a z-score of less than -1.5 in the d2 test than in the control group (total score I, HT vs. control group: 10 vs. 3, p=0.0302; total score II, HT vs. control group: 11 vs. 1, p=0.0013). The d2 test, which measures processing speed, rule compliance, and quality of performance, allows for a neuropsychological estimation of individual attention performance. HT patients with results below the normal range in the d2 attention test showed a significant increased mean value of anti-thyroid peroxidase antibodies compared to HT patients with normal test results (371.4+/-187.2IU/l vs. 69.3+/-28.7IU/l, p<0.05). In conclusion, our results point to subtle brain dysfunction in a subgroup of patients with HT even in euthyroid state. This could either be due to an association with an unknown autoimmune disorder affecting the CNS or a pathogenetic role of thyroid antibodies themselves.
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Affiliation(s)
- Thomas Leyhe
- Department of Psychiatry and Psychotherapy, University of Tübingen, Osianderstrasse 24, 72076 Tübingen, Germany.
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Abstract
Thyroid hormones play a critical role in the metabolic activity of the adult brain, and neuropsychiatric manifestations of thyroid disease have long been recognised. However, it is only recently that methodology such as functional neuroimaging has been available to facilitate investigation of thyroid hormone metabolism. Although the role of thyroid hormones in the adult brain is not yet specified, it is clear that without optimal thyroid function, mood disturbance, cognitive impairment and other psychiatric symptoms can emerge. Additionally, laboratory measurements of peripheral thyroid function may not adequately characterise central thyroid metabolism. Here, we review the relationship between thyroid hormone and neuropsychiatric symptoms in patients with primary thyroid disease and primary mood disorders.
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Affiliation(s)
- M Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Bocchetta A, Tamburini G, Cavolina P, Serra A, Loviselli A, Piga M. Affective psychosis, Hashimoto's thyroiditis, and brain perfusion abnormalities: case report. Clin Pract Epidemiol Ment Health 2007; 3:31. [PMID: 18096026 PMCID: PMC2235848 DOI: 10.1186/1745-0179-3-31] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Accepted: 12/20/2007] [Indexed: 11/10/2022]
Abstract
BACKGROUND It has recently become evident that circulating thyroid antibodies are found in excess among patients suffering from mood disorders. Moreover, a manic episode associated with Hashimoto's thyroiditis has recently been reported as the first case of bipolar disorder due to Hashimoto's encephalopathy. We report a case in which Hashimoto's thyroiditis was suspected to be involved in the deteriorating course of mood disorder and discuss potential pathogenic mechanisms linking thyroid autoimmunity with psychopathology. CASE PRESENTATION A 43-year-old woman, with a history of recurrent depression since the age of 31, developed manic, psychotic, and soft neurological symptoms across the last three years in concomitance with her first diagnosis of Hashimoto's thyroiditis. The patient underwent a thorough medical and neurological workup. Circulating thyroperoxidase antibodies were highly elevated but thyroid function was adequately maintained with L-thyroxine substitution. EEG was normal and no other signs of current CNS inflammation were evidenced. However, brain magnetic resonance imaging evidenced several non-active lesions in the white matter from both hemispheres, suggestive of a non-specific past vasculitis. Brain single-photon emission computed tomography showed cortical perfusion asymmetry particularly between frontal lobes. CONCLUSION We hypothesize that abnormalities in cortical perfusion might represent a pathogenic link between thyroid autoimmunity and mood disorders, and that the rare cases of severe Hashimoto's encephalopathy presenting with mood disorder might be only the tip of an iceberg.
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Affiliation(s)
- Alberto Bocchetta
- Sezione di Farmacologia Clinica, Dipartimento di Neuroscienze Bernard B Brodie, Università di Cagliari, Azienda Ospedaliero-Universitaria di Cagliari, via Ospedale 46, 09124 Cagliari, Italy.
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Abstract
This report describes a case of Hashimoto encephalopathy in an 11-year-old girl. She presented with features typical of this disorder including encephalopathy, seizures, and neuropsychiatric symptoms. Diagnosis was supported by an elevated thyroid-stimulating hormone level, a low levo-thyroxine level, and positive results for antithyroperoxidase antibody. Her response to typical treatment with levo-thyroxine was incomplete, requiring additional therapy with valproic acid and methylprednisone. Her course was further complicated by the development of acute psychosis. Treatment with risperidone was correlated with resolution of her psychosis and improvement in neuropsychiatric symptoms. Response to antipsychotic therapy has not previously been described in the pediatric population with Hashimoto encephalopathy. This case highlights the need for guidelines for the management of this rare disorder.
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Affiliation(s)
- Zia Bismilla
- Department of Pediatrics, Division of Pediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada.
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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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Bunevicius R, Peceliuniene J, Mickuviene N, Bunevicius A, Pop VJ, Girdler SS. Mood and thyroid immunity assessed by ultrasonographic imaging in a primary health care. J Affect Disord 2007; 97:85-90. [PMID: 16837056 DOI: 10.1016/j.jad.2006.05.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Revised: 05/16/2006] [Accepted: 05/25/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Psychiatric morbidity is highly prevalent in the primary health care settings and it may be related to autoimmune thyroid disease (AITD). The aim of this study was to evaluate the impact of thyroid immunity, evident by hypo-echoic thyroid ultrasound pattern, on prevalence of depression and anxiety in a primary care setting. METHODS In a cross-sectional design, 504 consecutive primary care patients were invited to the study and 474 patients completed the study. They were screened for depression and anxiety using the Hospital Anxiety and Depression Scale (HADS), were interviewed for affective disorders using the Mini International Neuropsychiatric Interview, and were evaluated by ultrasonographic imagining of the thyroid gland. RESULTS Among patients with hypo-echoic thyroid (n=122) prevailed women and those patients were older than patients with normo-echoic thyroid (n=352). Women, but not men, with hypo-echoic thyroid compared to those with normo-echoic thyroid had higher scores on the anxiety subscale of the HADS (p=0.03). Among women with hypo-echoic thyroid, only those pre-menopause, but not those post-menopause, had greater prevalence of high scores on the depression subscale of the HADS (p=0.02) and a greater likelihood of using psychiatric medications (p=0.001). LIMITATIONS Lack of cytological evaluation of the thyroid gland; lack of serum thyroid antibodies concentrations; and lack of thyroid hormone concentrations. CONCLUSIONS Thyroid immunity is related to mood symptoms in primary care patients. These effects are gender specific and in women, they are most evident before menopause.
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Affiliation(s)
- Robertas Bunevicius
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7160, USA.
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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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Carta MG, Hardoy MC, Carpiniello B, Murru A, Marci AR, Carbone F, Deiana L, Cadeddu M, Mariotti S. A case control study on psychiatric disorders in Hashimoto disease and Euthyroid Goitre: not only depressive but also anxiety disorders are associated with thyroid autoimmunity. Clin Pract Epidemiol Ment Health 2005; 1:23. [PMID: 16285879 PMCID: PMC1308833 DOI: 10.1186/1745-0179-1-23] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2005] [Accepted: 11/10/2005] [Indexed: 11/28/2022]
Abstract
Objective To evaluate the association between mood and anxiety disorders in Hashimoto disease and Euthyroid Goitre in a case control study. Methods Cases included 19 subjects with Hashimoto disease in euthyroid phase, 19 subjects with euthyroid goitre, 2 control groups each of 76 subjects matched (4/1) according to age and sex drawn from the data base of a community based sample. Psychiatric diagnoses were formulated using the International Composite Diagnostic Interview Simplified, according to DSM-IV criteria. All subjects underwent a complete thyroid evaluation including physical examination, thyroid echography and measure of serum free T4 (FT4), free T3 (FT3), thyroid-stimulating hormone (TSH) and anti-thyroid peroxidase autoantibodies (anti-TPO). Results: Subjects with Hashimoto disease showed higher frequencies of lifetime Depressive Episode (OR = 6.6, C.L. 95% 1.2–25.7), Generalized Anxiety Disorders (OR = 4,9 Cl 95% 1.5–25.4) and Social Phobia (OR = 20.0, CL 95% 2.3–153.3) whilst no differences were found between subjects with goitre and controls. Conclusion The study seems to confirm that risk for depressive disorders in subjects with thyroiditis is independent of the thyroid function detected by routine tests and indicates that not only mood but also anxiety disorders may be associated with Hashimoto disease.
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Affiliation(s)
- Mauro Giovanni Carta
- Division of Psychiatry, Department of Public Health, University of Cagliari, Italy
| | | | - Bernardo Carpiniello
- Division of Psychiatry, Department of Public Health, University of Cagliari, Italy
| | - Andrea Murru
- Division of Psychiatry, Department of Public Health, University of Cagliari, Italy
| | - Anna Rita Marci
- Division of Psychiatry, Department of Public Health, University of Cagliari, Italy
| | - Fiora Carbone
- Division of Psychiatry, Department of Public Health, University of Cagliari, Italy
| | - Luca Deiana
- Department of Internal Medicine, University of Cagliari, Italy
| | - Mariangela Cadeddu
- Division of Psychiatry, Department of Public Health, University of Cagliari, Italy
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Joergensen JV, Oerbeck B, Jebsen P, Heyerdahl S, Kase BF. Severe hypothyroidism due to atrophic thyroiditis from second year of life influenced developmental outcome. Acta Paediatr 2005; 94:1049-54. [PMID: 16188848 DOI: 10.1111/j.1651-2227.2005.tb02044.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED From the second year of life a girl showed an insidious development of clinical hypothyroidism due to a non-goitrous lymphocytic thyroiditis without traceable circulating levels of thyroid antibodies measured by routine immunoassays. The diagnostic delay of this rare variant of atrophic thyroiditis caused persistent neuropsychological deficits. CONCLUSION Her difficulties with speed of processing and working memory in particular could suggest a frontal deficit, possibly in the dorsolateral prefrontal circuit. This contrasts with findings in congenital hypothyroidism, suggesting a relatively preserved frontal function, and could illustrate different neuropsychological deficits of hypothyroidism at different ages in early childhood.
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Affiliation(s)
- J V Joergensen
- Department of Paediatric Research, Rikshospitalet University Hospital, Oslo, Norway
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Fatourechi V. Hashimoto's encephalopathy: myth or reality? An endocrinologist's perspective. Best Pract Res Clin Endocrinol Metab 2005; 19:53-66. [PMID: 15826922 DOI: 10.1016/j.beem.2004.11.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Since the first description of a case of episodic encephalopathy associated with Hashimoto's thyroiditis in 1966, many cases of corticosteroid-responsive encephalopathy associated with positive antithyroid antibodies, clinical Hashimoto's thyroiditis, or spontaneous autoimmune thyroid failure have been reported. These patients have neurologic manifestations of encephalopathy unrelated to other known causes. The condition has thus been termed 'Hashimoto's encephalopathy'. The literature shows no proven association between thyroid disease and the neurologic process. Although the association of a common endocrinologic condition and a rare neurologic disease may occur by chance, this type of encephalopathy probably has an autoimmune nature and thus is more likely to occur in the background of another autoimmune condition such as autoimmune thyroid disease. Until the pathogenesis of these coincident conditions is better defined, the term 'corticosteroid-responsive encephalopathy associated with autoimmune thyroiditis' is more accurate and descriptive than Hashimoto's encephalopathy. Advances in the field may clarify this seemingly inconsistent terminology.
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Affiliation(s)
- Vahab Fatourechi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Piga M, Serra A, Deiana L, Loi GL, Satta L, Di Liberto M, Mariotti S. Brain perfusion abnormalities in patients with euthyroid autoimmune thyroiditis. Eur J Nucl Med Mol Imaging 2004; 31:1639-44. [PMID: 15290119 DOI: 10.1007/s00259-004-1625-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Accepted: 06/08/2004] [Indexed: 11/28/2022]
Abstract
PURPOSE Brain perfusion abnormalities have recently been demonstrated by single-photon emission computed tomography (SPECT) in rare cases of severe Hashimoto's thyroiditis (HT) encephalopathy; moreover, some degree of subtle central nervous system (CNS) involvement has been hypothesised in HT, but no direct evidence has been provided so far. The aim of this study was to assess cortical brain perfusion in patients with euthyroid HT without any clinical evidence of CNS involvement by means of 99mTc-ECD brain SPECT. Sixteen adult patients with HT entered this study following informed consent. METHODS The diagnosis was based on the coexistence of high titres of anti-thyroid auto-antibodies and diffuse hypoechogenicity of the thyroid on ultrasound in association with normal circulating thyroid hormone and TSH concentrations. Nine consecutive adult patients with non-toxic nodular goitre (NTNG) and ten healthy subjects matched for age and sex were included as control groups. All patients underwent 99mTc-ECD brain SPECT. Image assessment was both qualitative and semiquantitative. Semiquantitative analysis was performed by generation of four regions of interest (ROI) for each cerebral hemisphere--frontal, temporal, parietal and occipital--and one for each cerebellar hemisphere in order to evaluate cortical perfusion asymmetry. The Asymmetry Index (AI) was calculated to provide a measurement of both magnitude and direction of perfusion asymmetry. RESULTS As assessed by visual examination, 99mTc-ECD cerebral distribution was irregular and patchy in HT patients, hypoperfusion being more frequently found in frontal lobes. AI revealed abnormalities in 12/16 HT patients, in three of the nine NTNG patients and in none of the normal controls. A significant difference in the mean AI was found between patients with HT and both patients with NTNG (p<0.003) and normal controls (p<0.001), when only frontal lobes were considered. CONCLUSION These results show the high prevalence of brain perfusion abnormalities in euthyroid HT. These abnormalities are similar to those observed in cases of severe Hashimoto's encephalopathy and may suggest a higher than expected involvement of CNS in thyroid autoimmune disease.
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Affiliation(s)
- M Piga
- Nuclear Medicine, Department of Medical Sciences M. Aresu, University of Cagliari, Cagliari, Italy.
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