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Maretta M, Lacková A, Wagnerová H, Feketeová E, Gdovinová Z. Steroid responsive encephalopathy associated with autoimmune thyroiditis as a cause of acuteencephalopathy. VNITRNI LEKARSTVI 2023; 69:25-29. [PMID: 37827820 DOI: 10.36290/vnl.2023.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), known as Hashimoto's encephalopathy (HE), represents a heterogeneous group of neurological and neuropsychiatric symptoms associated with a presence of antithyroid antibodies in case of other causes of encephalopathy were excluded. Clinical symptoms most commonly includes acute onset of encephalopathy, behaviour changes and cognitive dysfunction, epileptic seizures as well as cerebellar and extrapyramidal symptoms. Corticoids provides rapid and sustained therapeutic benefit in most patients and only a few patients require other immunosuppressive therapy such as plasmapheresis, intravenous immunoglobulins, or others. We present the cases of two patients with acute onset of encephalopathy, status epilepticus based on SREAT, with rapid improvement after steroid treatment.
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Manto MU. Endocrine Disorders. HANDBOOK OF THE CEREBELLUM AND CEREBELLAR DISORDERS 2022:2283-2300. [DOI: 10.1007/978-3-030-23810-0_92] [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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Menon V, Subramanian K, Thamizh JS. Psychiatric Presentations Heralding Hashimoto's Encephalopathy: A Systematic Review and Analysis of Cases Reported in Literature. J Neurosci Rural Pract 2019; 8:261-267. [PMID: 28479803 PMCID: PMC5402495 DOI: 10.4103/jnrp.jnrp_440_16] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Hashimoto's encephalopathy (HE) may often present initially with psychiatric symptoms. These presentations are often variable in clinical aspects, and there has been no systematic analysis of the numerous psychiatric presentations heralding an eventual diagnosis of HE which will guide clinicians to make a correct diagnosis of HE. This systematic review was done to analyze the demographic characteristics, symptom typology, and clinical and treatment variables associated with such forerunner presentations. Electronic databases such as PubMed, ScienceDirect, and Google Scholar databases were searched to identify potential case reports that described initial psychiatric presentations of HE in English language peer-reviewed journals. The generated articles were evaluated and relevant data were extracted using a structured tool. We identified a total of forty articles that described 46 cases. More than half of the total samples (54.4%) were above the age of 50 years at presentation. The most common psychiatric diagnosis heralding HE was acute psychosis (26.1%) followed by depressive disorders (23.9%). Dementia (10.9%) and schizophrenia (2.2%) were uncommon presentations. Antithyroid peroxidase antibodies were elevated in all patients but not antithyroglobulin antibodies. Preexisting hypothyroidism was absent in majority of cases (60.9%). Steroid doses initiated were 500-1000 mg of intravenous methylprednisolone for majority (52.1%) of patients while oral steroid maintenance was required for a significant minority (39.1%). Psychiatric manifestations of HE may be heterogeneous and require a high index of clinical suspicion, especially in older adults. A range of clinical and treatment variables may assist clinicians in making a faster diagnosis and instituting prompt and effective management.
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Affiliation(s)
- Vikas Menon
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Karthick Subramanian
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Manto M, Hampe CS. Endocrine disorders and the cerebellum: from neurodevelopmental injury to late-onset ataxia. HANDBOOK OF CLINICAL NEUROLOGY 2018; 155:353-368. [PMID: 29891071 DOI: 10.1016/b978-0-444-64189-2.00023-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Hormonal disorders are a source of cerebellar ataxia in both children and adults. Normal development of the cerebellum is critically dependent on thyroid hormone, which crosses both the blood-brain barrier and the blood-cerebrospinal fluid barrier thanks to specific transporters, including monocarboxylate transporter 8 and the organic anion-transporting polypeptide 1C1. In particular, growth and dendritic arborization of Purkinje neurons, synaptogenesis, and myelination are dependent on thyroid hormone. Disturbances of thyroid hormone may also impact on cerebellar ataxias of other origin, decompensating or aggravating the pre-existing ataxia manifesting with motor ataxia, oculomotor ataxia, and/or Schmahmann syndrome. Parathyroid disorders are associated with a genuine cerebellar syndrome, but symptoms may be subtle. The main conditions combining diabetes and cerebellar ataxia are Friedreich ataxia, ataxia associated with anti-GAD antibodies, autoimmune polyglandular syndromes, aceruloplasminemia, and cerebellar ataxia associated with hypogonadism (especially Holmes ataxia/Boucher-Neuhäuser syndrome). The general workup of cerebellar disorders should include the evaluation of hormonal status, including thyroid-stimulating hormone and free thyroxine levels, and hormonal replacement should be considered depending on the laboratory results. Cerebellar deficits may be reversible in some cases.
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Affiliation(s)
- Mario Manto
- Neurology Service, CHU-Charleroi, Charleroi, Belgium; Neuroscience Service, Université de Mons, Mons, Belgium.
| | - Christiane S Hampe
- Department of Medicine, University of Washington, Seattle, United States
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Endres D, Perlov E, Riering AN, Maier V, Stich O, Dersch R, Venhoff N, Erny D, Mader I, Tebartz van Elst L. Steroid-Responsive Chronic Schizophreniform Syndrome in the Context of Mildly Increased Antithyroid Peroxidase Antibodies. Front Psychiatry 2017; 8:64. [PMID: 28484400 PMCID: PMC5399039 DOI: 10.3389/fpsyt.2017.00064] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 04/06/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Schizophreniform syndromes can be divided into primary forms from polygenic causes or secondary forms due to immunological, epileptiform, monogenic, or degenerative causes. Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) is a secondary immunological form associated with increased thyroid antibodies, such as antithyroid peroxidase antibodies and shows a good response to corticosteroids. CASE PRESENTATION We present the case of a 41-year-old woman suffering from a schizophreniform syndrome. Starting at the age of 35, she developed psychotic exacerbations with formal thought disorder, acoustic hallucinations, cenesthopathic experiences, and loss of ego boundaries. At the same time, she began to suffer from chronic sexual delusions and olfactory hallucinations, which did not respond to neuroleptic medication. Her levels of antithyroid peroxidase antibodies were slightly increased, and the blood-brain barrier was disturbed. An electroencephalogram (EEG) showed intermittent generalized slowing, and cerebral magnetic resonance imaging (cMRI) depicted mild temporolateral atrophy. High-dose corticosteroid treatment led to convincing improvement of attentional performance and the disappearance of delusions and olfactory hallucinations. CONCLUSION SREAT can mimic typical symptoms of schizophreniform syndromes. The increased titer of antithyroid peroxidase antibodies in combination with the EEG slowing, blood-brain barrier dysfunction, and the cMRI alterations were the basis for suspecting an immunological cause in our patient. Chronic delusions, olfactory hallucinations, and cognitive deficits were successfully treated with corticosteroids. The occurrence of secondary immunological forms of schizophreniform syndromes demonstrates the need for innovative immunosuppressive treatment options.
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Affiliation(s)
- Dominique Endres
- Faculty of Medicine, Department of Psychiatry, Section for Experimental Neuropsychiatry, University of Freiburg, Freiburg, Germany
| | | | - Anne Nicole Riering
- Faculty of Medicine, Department of Psychiatry, Section for Experimental Neuropsychiatry, University of Freiburg, Freiburg, Germany
| | - Viktoria Maier
- Faculty of Medicine, Department of Psychiatry, Section for Experimental Neuropsychiatry, University of Freiburg, Freiburg, Germany
| | - Oliver Stich
- Faculty of Medicine, Department of Neurology, University of Freiburg, Freiburg, Germany
| | - Rick Dersch
- Faculty of Medicine, Department of Neurology, University of Freiburg, Freiburg, Germany
| | - Nils Venhoff
- Faculty of Medicine, Department of Rheumatology and Clinical Immunology, University of Freiburg, Freiburg, Germany
| | - Daniel Erny
- Faculty of Medicine, Institute of Neuropathology, University of Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Irina Mader
- Faculty of Medicine, Department of Neuroradiology, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Faculty of Medicine, Department of Psychiatry, Section for Experimental Neuropsychiatry, University of Freiburg, Freiburg, Germany
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Ransing RS, Mishra KK, Sarkar D. Neuropsychiatric Manifestation of Hashimoto's Encephalopathy in an Adolescent and Treatment. Indian J Psychol Med 2016; 38:357-60. [PMID: 27570351 PMCID: PMC4980907 DOI: 10.4103/0253-7176.185950] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Hashimoto's encephalopathy is usually underdiagnosed and untreated because of complex neuropsychiatric manifestation. We report a case of an adolescent female with Hashimoto's encephalopathy who responded well to a combination of aspirin and levothyroxine. A 16-year-old girl presented at psychiatric emergency services with a depressive episode, menstrual irregularities, and a 5-month past history of thyroid swelling. On clinical examination, she was in a euthyroid state with insignificant neurological history. However, her previous investigation revealed a hypothyroid state. Her magnetic resonance imaging findings demonstrated infarcts in the bilateral gangliocapsular region and left frontal periventricular deep white matter lesion. Ultrasonography of the thyroid and fine needle aspiration cytology confirmed lymphocytic thyroiditis. Anti-thyroid peroxidase (289 IU/ml) antibody titer was elevated (289 IU/mL). Her depressive symptoms responded well to antidepressants, mood stabilizers, nonsteroidal anti-inflammatory drugs, and levothyroxine. She remained in the euthyroid state and then in the euthymic state for 3 years. Hashimoto's encephalopathy is steroid-responsive encephalopathy. Most researchers have observed a dramatic response to steroids with or without levothyroxine. A clinician may consider aspirin as an alternative to a steroid in long-term management to avoid steroid-related side effects and contraindications.
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Affiliation(s)
- Ramdas Sarjerao Ransing
- Department of Psychiatry, B K L Walawalkar Rural Medical College, Ratnagiri, Maharashtra, India
| | - Kshirod Kumar Mishra
- Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
| | - Dipayan Sarkar
- Department of Psychiatry, Modern Psychiatric Hospital, Agartala, West Tripura, Tripura, India
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Vivek AK, Arun AB, Menon V, Kandasamy P. Acute polymorphic psychosis as a presenting feature of Hashimoto's encephalopathy. Asian J Psychiatr 2016; 19:19-20. [PMID: 26957330 DOI: 10.1016/j.ajp.2015.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 11/28/2015] [Accepted: 12/05/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Arun Kumar Vivek
- Dept. of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, Pondicherry 605006, India
| | - Anand Babu Arun
- Dept. of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, Pondicherry 605006, India
| | - Vikas Menon
- Dept. of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, Pondicherry 605006, India.
| | - Preeti Kandasamy
- Dept. of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, Pondicherry 605006, India
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Steiner J, Bernstein HG, Schiltz K, Müller UJ, Westphal S, Drexhage HA, Bogerts B. Immune system and glucose metabolism interaction in schizophrenia: a chicken-egg dilemma. Prog Neuropsychopharmacol Biol Psychiatry 2014; 48:287-94. [PMID: 23085507 DOI: 10.1016/j.pnpbp.2012.09.016] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Revised: 09/15/2012] [Accepted: 09/22/2012] [Indexed: 12/15/2022]
Abstract
Impaired glucose metabolism and the development of metabolic syndrome contribute to a reduction in the average life expectancy of individuals with schizophrenia. It is unclear whether this association simply reflects an unhealthy lifestyle or whether weight gain and impaired glucose tolerance in patients with schizophrenia are directly attributable to the side effects of atypical antipsychotic medications or disease-inherent derangements. In addition, numerous previous studies have highlighted alterations in the immune system of patients with schizophrenia. Increased concentrations of interleukin (IL)-1, IL-6, and transforming growth factor-beta (TGF-β) appear to be state markers, whereas IL-12, interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), and soluble IL-2 receptor (sIL-2R) appear to be trait markers of schizophrenia. Moreover, the mononuclear phagocyte system (MPS) and microglial activation are involved in the early course of the disease. This review illustrates a "chicken-egg dilemma", as it is currently unclear whether impaired cerebral glucose utilization leads to secondary disturbances in peripheral glucose metabolism, an increased risk of cardiovascular complications, and accompanying pro-inflammatory changes in patients with schizophrenia or whether immune mechanisms may be involved in the initial pathogenesis of schizophrenia, which leads to disturbances in glucose metabolism such as metabolic syndrome. Alternatively, shared underlying factors may be responsible for the co-occurrence of immune system and glucose metabolism disturbances in schizophrenia.
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Affiliation(s)
- Johann Steiner
- Department of Psychiatry, University of Magdeburg, Magdeburg, Germany; Center for Behavioral Brain Sciences, Magdeburg, Germany.
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A selective memory deficit caused by autoimmune encephalopathy associated with Hashimoto thyroiditis. Cogn Behav Neurol 2013; 25:144-8. [PMID: 22960439 DOI: 10.1097/wnn.0b013e31826b7ed7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a longstanding selective memory deficit in a euthyroid 45-year-old woman who was being treated with levothyroxine for Hashimoto thyroiditis. The patient had complained of memory problems and deterioration of her concentration skills for about 2 years. Her endocrinologist thought that she was depressed. The patient's physical examination was normal. She scored a full 30 points on the Mini-Mental State Examination, but neuropsychological evaluation showed a significant deficit in her verbal memory. Routine blood tests and cerebrospinal fluid analysis showed only antithyroid peroxidase antibodies. Brain magnetic resonance imaging was normal. Electroencephalogram showed scarce intermittent bilateral multifocal theta waves. We increased the patient's daily dose of levothyroxine and started her on dexamethasone therapy. Five months later, we repeated the entire evaluation and found both her cognitive function and her electroencephalogram to be normal. Autoimmune encephalopathy associated with Hashimoto thyroiditis is already known to present with either stroke-like episodes or diffuse progressive deterioration. Our patient shows that the encephalopathy can present as a chronic selective memory deficit that can spare executive functions and short-term memory. This presentation can be missed or mistaken for depression, but can be diagnosed with a detailed neuropsychological evaluation.
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Manto M. Endocrine Disorders. HANDBOOK OF THE CEREBELLUM AND CEREBELLAR DISORDERS 2013:2009-2025. [DOI: 10.1007/978-94-007-1333-8_92] [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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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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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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Liu CY, Tseng MCM, Lin PH. Encephalopathy associated with autoimmune thyroid disease (Hashimoto's thyroiditis) presenting as depression: a case report. Gen Hosp Psychiatry 2011; 33:641.e7-9. [PMID: 21762998 DOI: 10.1016/j.genhosppsych.2011.05.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 05/25/2011] [Accepted: 05/27/2011] [Indexed: 11/29/2022]
Abstract
Encephalopathy associated with autoimmune thyroid disease (EAATD) is a rare condition associated with Hashimoto's thyroiditis or Graves' disease. It is often underdiagnosed because of the various clinical presentations and lack of widely accepted diagnostic criteria. We report a 46-year-old man who presented with an acute depressive episode and was proven to have encephalopathy associated with Hashimoto's thyroiditis. The exclusive psychiatric manifestations of this case called our attention to the fact that an improved awareness of EAATD in patients with a history of thyroid disease can lead to a timely diagnosis and excellent disease prognosis.
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Affiliation(s)
- Chao-Yu Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, 10002, Taiwan
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Lee SW, Donlon S, Caplan JP. Steroid Responsive Encephalopathy Associated with Autoimmune Thyroiditis (SREAT) or Hashimoto's Encephalopathy: A Case and Review. PSYCHOSOMATICS 2011; 52:99-108. [DOI: 10.1016/j.psym.2010.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 03/22/2010] [Accepted: 03/23/2010] [Indexed: 10/14/2022]
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