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Takahashi N, Shikama Y, Kawahara H, Okabe Y, Kurimura M, Ohta Y. [A case of Hashimoto's encephalopathy with acute onset of psychiatric symptoms and diffuse deep white matter lesions on brain MRI]. Rinsho Shinkeigaku 2024; 64:171-175. [PMID: 38382936 DOI: 10.5692/clinicalneurol.cn-001905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
A 51-year-old man developed acute disturbances in consciousness and psychiatric symptoms one month prior to admission. He was referred and admitted to the Department of Psychiatry of our hospital and transferred to the neurology department because diffuse white matter lesions were found on his brain during MRI. 123I-IMP-SPECT showed extensive cerebral hypoperfusion mainly in the frontal lobes. Anti-Tg, anti-TPO, and anti-NAE antibodies were positive. These findings led to a diagnosis of Hashimoto's encephalopathy. The patient responded to steroid pulse therapy, high-dose steroid therapy, and intravenous immunoglobulin therapy, showing improvement in symptoms and imaging findings. Hashimoto's encephalopathy often presents with MRI findings similar to those of limbic encephalitis, when the patient presents with acute consciousness disturbance and psychiatric symptoms. However, this case showed diffuse white matter lesions, which may be clinically important for the differential diagnosis.
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Affiliation(s)
| | | | - Hikaru Kawahara
- Division of Neurology and Clinical Neuroscience, Department of Internal Medicine III, Yamagata University School of Medicine
| | - Yuma Okabe
- Department of Neurology, Okitama Public General Hospital
| | | | - Yasuyuki Ohta
- Division of Neurology and Clinical Neuroscience, Department of Internal Medicine III, Yamagata University School of Medicine
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Şorodoc V, Constantin M, Asaftei A, Lionte C, Ceasovschih A, Sîrbu O, Haliga RE, Şorodoc L. The use of intravenous immunoglobulin in the treatment of Hashimoto's encephalopathy: case based review. Front Neurol 2023; 14:1243787. [PMID: 37745658 PMCID: PMC10513043 DOI: 10.3389/fneur.2023.1243787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Abstract
Background Hashimoto's encephalopathy (HE) is a controversial immunological neuropsychiatric disease, with a poorly understood pathogenesis. It is characterized by symptoms of acute or subacute encephalopathy which usually occur in the presence of elevated levels of antithyroid antibodies. Even though it is also known as steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT), some cases appear to be steroid-resistant. This review examined whether treatment of Hashimoto's encephalopathy with intravenous immunoglobulin (IVIG) is associated with better clinical outcomes than the standard therapy. Additionally, we presented a case of a 59-year-old man who presented with severe neurological manifestations and was successfully treated with intravenous immunoglobulin. Methods The online databases PubMed and EMBASE were searched. Results A total of 1,365 articles were identified. After the deletion of 112 duplicates, 1,253 studies were screened by evaluating the title and abstract, focusing on Hashimoto's encephalopathy cases where IVIG were used. 846 studies were excluded because they were not relevant to the topic or included pediatric population. Therefore, 407 full-text articles were assessed for eligibility. The final analysis included 14 eligible articles after 393 were excluded (irrelevant texts, not written in English, full-text not available). In the majority of the selected case-reports, IVIG was associated with a good outcome, sometimes even with dramatic improvements in patient's status. Conclusion In last years, intravenous immunoglobulin therapy proved its utility in Hashimoto's encephalopathy's treatment, being a well tolerated therapy associated with remarkable improvement in patient's status. Further research is still needed in order to define the optimal treatment protocol for Hashimoto's encephalopathy and to establish if intravenous immunoglobulin can also be used as a first-line therapy, alone or in combination with steroids.
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Affiliation(s)
- Victoriţa Şorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Mihai Constantin
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Andreea Asaftei
- 2nd Rheumatology Department, Clinical Rehabilitation Hospital, Iasi, Romania
| | - Cătălina Lionte
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Alexandr Ceasovschih
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Oana Sîrbu
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Raluca Ecaterina Haliga
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Laurenţiu Şorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
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Kawoos Y, Fayaz A, Shah IA, Rather YH. Hashimoto’s encephalopathy masquerading as affective illness: a case report. MIDDLE EAST CURRENT PSYCHIATRY 2022. [DOI: 10.1186/s43045-022-00244-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract
Background
Hashimoto’s encephalopathy (HE) is a rare but controversial syndrome showing a variety of neurological and psychiatric manifestations associated with autoimmune thyroiditis.
Case presentation
We present a case of 46-year-old hypertensive female who developed acute onset of behavioral symptoms mimicking affective disorder (mania). Investigations revealed high levels of anti-thyroid peroxidase antibodies with elevated thyroid-stimulating hormone. EEG and MRI findings were consistent with those seen in Hashimoto’s encephalopathy. She showed excellent response to high dose corticosteroids that helped in making the diagnosis of Hashimoto’s encephalopathy.
Conclusions
Hashimoto’s encephalopathy is an extremely important, though rare, diagnosis. It should be suspected and screened for in patients with encephalopathy of unknown origin because responses to treatment are usually excellent.
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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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Ishihara K, Naitoh Y, Fukui Y, Asahi T. [A case of Hashimoto's encephalopathy showing improvement in higher brain functions after a low-dose steroid therapy]. Rinsho Shinkeigaku 2019; 59:570-574. [PMID: 31474641 DOI: 10.5692/clinicalneurol.cn-001301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Here, we describe a case involving an 83-year-old woman who was admitted to our hospital for rehabilitation after pseudogout treatment. She had temporal and spatial disorientation. Neuropsychological assessment revealed frontal dysfunction, memory impairment, and executive dysfunction, in addition to general cognitive impairment. Subsequent laboratory examination revealed euthyroid status and elevated titers of anti-thyroid autoantibodies. MRI of the brain revealed no abnormal finding. However, electroencephalography revealed diffuse slowness. We diagnosed Hashimoto's encephalopathy on the basis of the clinical symptoms and laboratory findings. Administration of low-dose prednisolone (5 mg/day) alleviated general cognitive impairment and the laboratory findings; however, memory impairment and construction disorder remained. Previous studies suggest that the characteristics and clinical course of higher brain-function disorder associated with Hashimoto's encephalopathy vary on an individual basis, wherein some patients may respond well to low-dose steroid therapy. Here, we also encountered such a case, that showed good response to a low-dose steroid therapy.
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Affiliation(s)
- Kenji Ishihara
- Department of Neurology, Asahi Hospital of Neurology and Rehabilitation
| | - Yurino Naitoh
- Department of Rehabilitation, Asahi Hospital of Neurology and Rehabilitation
| | - Yasuhito Fukui
- Department of Clinical Psychology, Asahi Hospital of Neurology and Rehabilitation
| | - Toshiomi Asahi
- Department of Neurology, Asahi Hospital of Neurology and Rehabilitation
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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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Ikawa F, Sumi N, Nishikawa T, Maruyama H, Miyachi T. [A case of dementia with Lewy bodies and Hashimoto encephalopathy successfully treated with immunotherapy]. Rinsho Shinkeigaku 2019; 59:102-104. [PMID: 30700687 DOI: 10.5692/clinicalneurol.cn-001204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
We report a 77-year-old woman suffering from dementia with Lewy bodies (DLB) who presented with Hashimoto encephalopathy. The patient began to mistakenly believe that another person was sleeping in her bed from approximately 70 years of age. She began to show symptoms of parkinsonism after 75 years of age. One night, the patient began to exhibit loitering behavior, and made incomprehensible comments while also exhibiting other abnormal behaviors. Clinical examination revealed rigidity and tremor of the limbs, as well as hallucination, abnormal speech and behavior. We first considered DLB. However, serum anti-thyroglobulin levels turned out to be elevated, indicating Hashimoto encephalopathy as well, and treated the patient with steroid pulse therapy. Her mental symptoms subsequently improved, but rigidity and tremor remained. 123I-ioflupane SPECT demonstrated decreased accumulation in the bilateral caudal basal ganglia. Anti NH2-terminal of α-enolase (NAE) antibody in the serum was positive. Therefore, we diagnosed the patient with the rare comorbidity of DLB and Hashimoto encephalopathy, successfully treated with immunotherapy.
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Affiliation(s)
- Fumiaki Ikawa
- Department of Neurology, Yanai Medical Center, National Hospital Organization
- Present address: Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Naoko Sumi
- Department of Neurology, Yanai Medical Center, National Hospital Organization
- Present address: Department of Neurology, Hiroshima City Hospital
| | - Tomokazu Nishikawa
- Department of Neurology, Yanai Medical Center, National Hospital Organization
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Takafumi Miyachi
- Department of Neurology, Yanai Medical Center, National Hospital Organization
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Termsarasab P, Pitakpatapee Y, Frucht SJ, Srivanitchapoom P. Steroid-responsive Encephalopathy Associated with Autoimmune Thyroiditis (SREAT) Presenting with Pure Cerebellar Ataxia. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2018; 8:585. [PMID: 30191089 PMCID: PMC6125737 DOI: 10.7916/d8cz4qqq] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 07/16/2018] [Indexed: 12/30/2022]
Abstract
Background Myoclonus and tremor are common movement disorder phenomenologies in steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT). Pure ataxia without encephalopathy has rarely been reported. Case report We report 21- and 40-year-old females who presented with subacute pure ataxia without encephalopathy. After immunotherapies, both exhibited initial improvement of ataxia, and subsequently remained in plateau phase. Discussion This treatable disorder should be added to the differential diagnoses of progressive cerebellar ataxia, and anti-thyroid peroxidase and anti-thyroglobulin should be considered as part of the workup. It is crucial not to misdiagnose SREAT presenting with pure cerebellar ataxia as degenerative or spinocerebellar ataxia.
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Affiliation(s)
- Pichet Termsarasab
- Neurology Division, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yuvadee Pitakpatapee
- Neurology Division, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Steven J Frucht
- Movement Disorder Division, Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Prachaya Srivanitchapoom
- Neurology Division, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Kong FX, Lu QH, Guo ZK. Multiple intracranial lesions as the unusual imaging features of Hashimoto's encephalopathy: A case report. Medicine (Baltimore) 2018; 97:e10814. [PMID: 29794766 PMCID: PMC6393037 DOI: 10.1097/md.0000000000010814] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Hashimoto's encephalopathy (HE) is associated with autoimmune thyroid disease and is complex, diverse, and easily misdiagnosed. However, if HE is diagnosed and treated in a timely manner, an optimal prognosis may be achieved. PATIENT CONCERNS We presented a case of a 63-year-old female patient with paroxysmal dizziness, unsteady gait, emotion apathy, progressive cognitive impairment, and unusual magnetic resonance imaging (MRI) findings. DIAGNOSES After suffering for almost 8 years, the patient was diagnosed with HE based on clinical manifestation, abnormal electroencephalogram, unusual MRI findings, sensitivity to cortisol treatment, and characteristic high antithyroid peroxidase antibody (TpoAb) titer. INTERVENTIONS The patient continued regular glucocorticoids therapy after intravenous methylprednisolone pulse therapy, neurotrophic drugs, traditional Chinese medicine and rehabilitation to relieve hypermyotonia and cognitive impairment. OUTCOMES After combined treatment, the patient's symptoms, electroencephalogram (EEG), MRI, and the TpoAb titer gradually improved. However, the patient had to stop glucocorticoids treatment because of severe osteoporosis, fractures and other adverse reactions. Her symptoms fluctuated, and her TpoAb titer increased again. LESSONS HE may cause highly heterogeneous clinical features, particularly MRI findings. Withdrawal of the systematic glucocorticoids treatment can lead to varied outcomes in these patients.
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Affiliation(s)
- Fan-Xin Kong
- Guangzhou University of Chinese Medicine Clinical Medical School of Shenzhen
- Department of Encephalopathy and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
| | - Qing-Hong Lu
- Guangzhou University of Chinese Medicine Clinical Medical School of Shenzhen
| | - Zhou-Ke Guo
- Department of Encephalopathy and Psychology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
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Hashimoto encephalopathy in pediatric patients: Homogeneity in clinical presentation and heterogeneity in antibody titers. Brain Dev 2018; 40:42-48. [PMID: 28784301 DOI: 10.1016/j.braindev.2017.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/19/2017] [Accepted: 07/20/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Hashimoto encephalopathy is an autoimmune encephalopathy characterized by elevated antithyroid antibodies and a favorable response to corticosteroid. This study delineated the clinical characteristics of pediatric Hashimoto encephalopathy and the significance of low antithyroid antibody titers in diagnosis and treatment. SUBJECTS AND METHODS Clinical manifestations, antibody titers, and treatment responses were retrospectively reviewed in six consecutive children diagnosed with Hashimoto encephalopathy between August 2008 and July 2016. RESULTS Age at diagnosis was 10-17years. Presenting symptoms were seizures, altered consciousness, behavioral changes, psychosis, tremor, and dystonia. Thyroid function was normal in five patients, and one had hypothyroidism prior to the encephalopathy. Antithyroid antibody titer was increased at presentation in five patients and one week later in the other. Antibody levels were extremely varied (anti-thyroglobulin, 20.5-2318.0U/ml; anti-thyroid peroxidase, 12.5-2231.0U/ml; reference range, <60U/ml) and <180U/ml in two patients. Electroencephalogram was abnormal in five patients. Brain magnetic resonance imaging was unremarkable. Four patients responded to high-dose corticosteroid and one improved with additional intravenous immunoglobulin. The remaining patient did not respond to both treatments and normalized after plasmapheresis. Autoantibody titers decreased with treatment response in the acute stage. Two patients with low antibody titers showed similar clinical presentations and responses. CONCLUSIONS The clinical presentations and treatment responses in Hashimoto encephalopathy were similar, irrespective of antithyroid antibody titer. Because the initial antithyroid antibody titers can be normal or mildly-elevated, follow-up testing of antithyroid antibodies is required in patients who are clinically suspect for Hashimoto encephalopathy.
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Álvarez Bravo G, Yusta Izquierdo A, Carvalho Monteiro G, Sánchez I. Cerebellopathy secondary to anti-peroxidase antibody-mediated toxicity. A special case of Hashimoto encephalopathy. J Neuroimmunol 2017; 312:1-3. [PMID: 28863961 DOI: 10.1016/j.jneuroim.2017.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 08/02/2017] [Accepted: 08/18/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of this case report is to highlight the importance of recognizing uncommon causes of cerebellar involvement. CASE PRESENTATION A 45-year-old woman with no medical history who presented gait instability that appears suddenly and evolves rapidly in two weeks, causing frequent falls. Neurological examination revealed an inability to walk due to severe ataxia, accompanied by global hypotonia, appendicular dysmetria, opsoclonus and dysarthria. We studied this patient with cerebellar syndrome, obtaining as relevant findings global cerebellar atrophy in MRI (magnetic resonance imaging) and especially, considerably elevated levels of antibodies against thyroid peroxidase (TPO). The patient was treated with high doses of intravenous methylprednisolone for 5days. Six months after diagnosis and in treatment with low doses of prednisone, the patient is asymptomatic. CONCLUSION We must considerer the cerebellar involvement secondary to steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT) in a patient in whom other more frequent causes of isolated cerebellar disease have been ruled out.
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Affiliation(s)
| | | | | | - Irene Sánchez
- Department of Neurology, Hospital of Guadalajara, Spain
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Kishitani T, Matsunaga A, Ikawa M, Hayashi K, Yamamura O, Hamano T, Watanabe O, Tanaka K, Nakamoto Y, Yoneda M. Limbic encephalitis associated with anti-NH2-terminal of α-enolase antibodies: A clinical subtype of Hashimoto encephalopathy. Medicine (Baltimore) 2017; 96:e6181. [PMID: 28272206 PMCID: PMC5348154 DOI: 10.1097/md.0000000000006181] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Several types of autoantibodies have been reported in autoimmune limbic encephalitis (LE), such as antibodies against the voltage-gated potassium channel (VGKC) complex including leucine-rich glioma inactivated 1 (LGI1). We recently reported a patient with autoimmune LE and serum anti-NH2-terminal of α-enolase (NAE) antibodies, a specific diagnostic marker for Hashimoto encephalopathy (HE), who was diagnosed with HE based on the presence of antithyroid antibodies and responsiveness to immunotherapy. This case suggests that LE patients with antibodies to both the thyroid and NAE could be diagnosed with HE and respond to immunotherapy. The aim of this study was to clarify the clinicoimmunological features and efficacy of immunotherapy in LE associated with anti-NAE antibodies to determine whether the LE is a clinical subtype of HE.We examined serum anti-NAE antibodies in 78 LE patients with limbic abnormality on magnetic resonance imaging and suspected HE based on positivity for antithyroid antibodies. Nineteen of the 78 patients had anti-NAE antibodies; however, 5 were excluded because they were double positive for antibodies to the VGKC complex including LGI1. No antibodies against the N-methyl-D-aspartate receptor (NMDAR), contactin-associated protein 2 (Caspr2), γ-aminobutyric acid-B receptor (GABABR), or α-amino-3-hydroxy-5-methylisoxazole-4-propionic acid receptor (AMPAR) were detected in the 19 patients. Among the remaining 14 who were positive only for anti-NAE antibodies, the median age was 62.5 (20-83) years, 9 (64%) were women, and 8 (57%) showed acute onset, with less than 2 weeks between onset and admission. Consciousness disturbance (71%) and memory disturbance (64%) were frequently observed, followed by psychiatric symptoms (50%) and seizures (43%). The frequency of these symptoms significantly differed between the acute- and subacute-onset groups. Abnormalities in cerebrospinal fluid and electroencephalogram were commonly observed (92% for both). Tumors were not identified in any cases. All patients responded to immunotherapy or spontaneously remitted, thereby fulfilling the criteria of HE.This study demonstrated that LE associated with anti-NAE antibodies is a nonparaneoplastic LE and various limbic symptoms that depend on the onset type. Favorable therapeutic efficacy suggests that this LE can be considered a clinical subtype of HE and that anti-NAE antibodies may be a promising indicator of the need for immunotherapy.
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Affiliation(s)
- Toru Kishitani
- The Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui
| | - Akiko Matsunaga
- The Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui
| | - Masamichi Ikawa
- The Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui
| | - Kouji Hayashi
- The Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui
| | - Osamu Yamamura
- The Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui
| | - Tadanori Hamano
- The Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui
| | - Osamu Watanabe
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima
| | - Keiko Tanaka
- Department of Neurology, Kanazawa Medical University, Ishikawa
| | - Yasunari Nakamoto
- The Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui
| | - Makoto Yoneda
- Faculty of Nursing and Social Welfare Sciences, Fukui Prefectural University, Fukui, Japan
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Psychosis Crisis Associated with Thyrotoxicosis due to Graves’ Disease. Case Rep Psychiatry 2017; 2017:6803682. [PMID: 28695035 PMCID: PMC5485298 DOI: 10.1155/2017/6803682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 05/08/2017] [Accepted: 05/18/2017] [Indexed: 11/27/2022] Open
Abstract
We present the case of a patient with previous psychiatric illness, acutely exacerbated by thyroid storm due to Graves' disease, in whom treatment with antipsychotics induced catatonia. These associations are extremely rare and may be confused with Hashimoto's encephalopathy, especially in the presence of anti-thyroid antibodies in cerebrospinal fluid. The treatment consists in the control of the triggering disease (in this case the resolution of the thyrotoxicosis) and the use of benzodiazepines. However, in some cases, the resolution of psychiatric symptoms is partial and may require the use of electroconvulsive therapy.
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Horikoshi S, Miura I, Kunii Y, Asano S, Kanno-Nozaki K, Mashiko H, Yabe H. Hashimoto encephalopathy with high plasma monoamine metabolite levels: a case report. Neuropsychiatr Dis Treat 2017; 13:1043-1045. [PMID: 28435274 PMCID: PMC5391161 DOI: 10.2147/ndt.s131356] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hashimoto encephalopathy (HE) is believed to be an immune-mediated disorder associated with Hashimoto's thyroiditis. It was suggested that neuropsychiatric symptoms, the presence of antithyroid antibody, and good response to steroids were important for the diagnosis of HE. It has been reported that homovanillic acid (HVA) and 3-methoxy-4-hydroxyphenylglycol (MHPG), which are monoamine metabolites of dopamine and noradrenaline, respectively, are the possible biomarkers of neuropsychiatric diseases. We report a case of Hashimoto encephalopathy, in which we longitudinally measured the plasma levels of monoamine metabolites. A 52-year-old woman developed acute psychosis, and was admitted to the psychiatric ward of our hospital due to psychotic state, 6 days after a traffic accident. An extensive evaluation showed no remarkable findings, except an increase in antithyroglobulin antibodies. Plasma levels of HVA and MHPG were extremely high at 66.5 and 41.8 ng/mL, respectively. On day 16, 50 mg/day oral prednisolone was administered, which improved her psychotic symptoms. Plasma levels of HVA and MHPG decreased to 7.2 and 9.9 ng/mL, respectively, on day 19. After the temporary worsening of psychosis and increase in plasma levels of HVA and MHPG, the dosage of prednisolone was tapered and low-dose risperidone was started. Her psychiatric symptoms gradually improved and plasma monoamine metabolite levels decreased again (HVA: 17.9 ng/mL; MHPG: 7.7 ng/mL). Although autoimmune mechanism has been suggested to be involved in HE, neural mechanism and pathogenesis of HE remain unknown. Our findings suggest that monoaminergic neural activity might be associated with psychotic symptoms in patients with HE and plasma levels of monoamine metabolites might be useful as state markers.
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Affiliation(s)
- Sho Horikoshi
- Department of Neuropsychiatry, Hoshi General Hospital.,Department of Neuropsychiatry, Fukushima Medical University School of Medicine
| | - Itaru Miura
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine
| | - Yasuto Kunii
- Department of Neuropsychiatry, Fukushima Medical University School of Aizu Medical Center
| | - Satoko Asano
- Department of Neuropsychiatry, Japan Red Cross Fukushima Hospital
| | - Keiko Kanno-Nozaki
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine
| | - Hirobumi Mashiko
- Department of Neuropsychiatry, Fukushima Prefectural General Rehabilitation Center, Fukushima, Japan
| | - Hirooki Yabe
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine
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Sato R, Takada T, Nasu M. Hashimoto Encephalopathy: A Case Report. Am J Med 2016; 129:e187. [PMID: 27154779 DOI: 10.1016/j.amjmed.2016.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 04/16/2016] [Accepted: 04/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Ryota Sato
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan.
| | - Tadaaki Takada
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Michitaka Nasu
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
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Das M, Kayal AK, Goswami M, Basumatary LJ, Bhowmick S, Synmon B. Spectrum of Hashimoto's encephalopathy – An experience from the North East India. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2016. [DOI: 10.1016/j.injms.2016.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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Mitoma H, Adhikari K, Aeschlimann D, Chattopadhyay P, Hadjivassiliou M, Hampe CS, Honnorat J, Joubert B, Kakei S, Lee J, Manto M, Matsunaga A, Mizusawa H, Nanri K, Shanmugarajah P, Yoneda M, Yuki N. Consensus Paper: Neuroimmune Mechanisms of Cerebellar Ataxias. CEREBELLUM (LONDON, ENGLAND) 2016; 15:213-32. [PMID: 25823827 PMCID: PMC4591117 DOI: 10.1007/s12311-015-0664-x] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the last few years, a lot of publications suggested that disabling cerebellar ataxias may develop through immune-mediated mechanisms. In this consensus paper, we discuss the clinical features of the main described immune-mediated cerebellar ataxias and address their presumed pathogenesis. Immune-mediated cerebellar ataxias include cerebellar ataxia associated with anti-GAD antibodies, the cerebellar type of Hashimoto's encephalopathy, primary autoimmune cerebellar ataxia, gluten ataxia, Miller Fisher syndrome, ataxia associated with systemic lupus erythematosus, and paraneoplastic cerebellar degeneration. Humoral mechanisms, cell-mediated immunity, inflammation, and vascular injuries contribute to the cerebellar deficits in immune-mediated cerebellar ataxias.
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Affiliation(s)
- Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan.
| | - Keya Adhikari
- Department of Haematology, Nil Ratan Sircar Medical College, 138 A J C Bose Road, Kolkata, 700014, West Bengal, India
| | - Daniel Aeschlimann
- Matrix Biology &Tissue Repair Research Unit, School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Cardiff, Wales, UK
| | - Partha Chattopadhyay
- Department of General Medicine, College of Medicine & Sagore Dutta Hospital, 578 B T Road, Kamarhati-Kolkata, 700056, West Bengal, India
| | | | - Christiane S Hampe
- School of Medicine, University of Washington, 850 Republication, Seattle, WA, 98109, USA
| | - Jérôme Honnorat
- University Lyon 1, University Lyon, Rue Guillaume Paradin, 69372, Lyon Cedex 08, France
- INSERM, UMR-S1028, CNRS, UMR-5292, Neuro-Oncology and Neuro-Inflammation Team, 7, Lyon Neuroscience Research Center, Rue Guillaume Paradin, 69372, Lyon Cedex 08, France
- National Reference Centre for Paraneoplastic Neurological Diseases, Hospices Civils de Lyon, Hôpital Neurologique, 69677, Bron, France
- Hospices Civils de Lyon, Neuro-oncology, Hôpital Neurologique, 69677, Bron, France
| | - Bastien Joubert
- University Lyon 1, University Lyon, Rue Guillaume Paradin, 69372, Lyon Cedex 08, France
- INSERM, UMR-S1028, CNRS, UMR-5292, Neuro-Oncology and Neuro-Inflammation Team, 7, Lyon Neuroscience Research Center, Rue Guillaume Paradin, 69372, Lyon Cedex 08, France
| | - Shinji Kakei
- Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Jongho Lee
- Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Mario Manto
- Unité d'Etude du Mouvement, FNRS, Neurologie ULB-Erasme, 808 Route de Lennik, 1070, Brussels, Belgium
| | - Akiko Matsunaga
- Department of Neurology, University of Fukui Hospital, Fukui, Japan
| | | | - Kazunori Nanri
- Department of Neurology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Priya Shanmugarajah
- Academic Department of Neurosciences, Royal Hallamshire Hospital, Sheffield, UK
| | - Makoto Yoneda
- Faculty of Nursing and Social Welfare Sciences, Fukui Prefectural University, Fukui, Japan
| | - Nobuhiro Yuki
- Departments of Medicine and Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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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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Nandi-Munshi D, Taplin CE. Thyroid-related neurological disorders and complications in children. Pediatr Neurol 2015; 52:373-82. [PMID: 25661286 DOI: 10.1016/j.pediatrneurol.2014.12.005] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 12/23/2014] [Accepted: 12/25/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Thyroid hormones exert critical roles throughout the body and play an important and permissive role in neuroendocrine, neurological, and neuromuscular function. METHODS We performed a PubMed search through June 2014 with search terms including "hypothyroidism," "hyperthyroidism," "neurological complications," "neuropathy," "myopathy," "congenital hypothyroidism," and "encephalopathy." Relevant publications reviewed included case series, individual case reports, systematic reviews, retrospective analyses, and randomized controlled trials. The neurological outcomes of congenital hypothyroidism were reviewed, along with the clinical features of associated neuromuscular syndromes of both hypothyroidism and hyperthyroidism, including other autoimmune conditions. Evidence for, and pathophysiological controversies surrounding, Hashimoto encephalopathy was also reviewed. RESULTS The establishment of widespread newborn screening programs has been highly successful in attenuating or preventing early and irreversible neurological harm resulting from congenital thyroid hormone deficiency, but some children continue to display neuromuscular, sensory, and cognitive defects in later life. Acquired disorders of thyroid function such as Hashimoto thyroiditis and Graves' disease are associated with a spectrum of central nervous system and/or neuromuscular dysfunction. However, considerable variation in clinical phenotype is described, and much of our knowledge of the role of thyroid disease in childhood neurological disorders is derived from adult case series. CONCLUSIONS Early and aggressive normalization of thyroxine levels in newborn infants with congenital hypothyroidism is important in minimizing neurological sequelae, but maternal thyroid hormone sources are also critically important to the early developing brain. A spectrum of neurological disorders has been reported in older children with acquired thyroid disease, but the frequency with which these occur remains poorly defined in the literature, and much must be extrapolated from adult data. A high index of suspicion for acquired thyroid disease is paramount in the investigation of many neurological disorders of youth, as many reported sequelae of hypothyroidism and hyperthyroidism are reversible with appropriate endocrine management.
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Affiliation(s)
- Debika Nandi-Munshi
- Division of Endocrinology and Diabetes, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Craig E Taplin
- Division of Endocrinology and Diabetes, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington.
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Riangwiwat T, Sangtian J, Sriphrapradang C. Steroid-responsive encephalopathy: an under recognised aspect of Hashimoto's thyroiditis. BMJ Case Rep 2015; 2015:bcr-2014-208969. [PMID: 25766444 DOI: 10.1136/bcr-2014-208969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of a patient who was diagnosed with Hashimoto's encephalopathy based on the presence of subacute behavioural changes, negative work up for infection and immunological serology except for high serum titres of thyroid autoantibodies. Thyroid function tests (TFTs) and MRI of the brain were normal. EEG showed low amplitude, slow waves and θ waves at both frontal areas. His condition improved dramatically after treated with high-dose glucocorticoid. After 2 years of a relapsing-remitting course, a new episode occurred. There was an abrupt change of TFTs within 5 days: free thyroxine (fT4) from 1.52 to 1.53 ng/mL, free triiodothyronine (fT3) from 3.25 to >30 pg/mL and thyroid-stimulating hormone (TSH) from 5.08 to 0.78 mIU/L. On the following day found fT4 2.58, fT3 14.67 and TSH 0.042. The patient was diagnosed with Hashitoxicosis. High-dose glucocorticoid and β-blockers were initiated. The symptoms gradually improved and TFTs normalised within 2 weeks.
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Affiliation(s)
- Tanawan Riangwiwat
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University,Thailand
| | - Jutarat Sangtian
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University,Thailand
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Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT): case report of reversible coma and status epilepticus in an adolescent patient and review of the literature. Eur J Pediatr 2014; 173:1263-73. [PMID: 25084973 DOI: 10.1007/s00431-014-2391-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 07/22/2014] [Accepted: 07/24/2014] [Indexed: 01/18/2023]
Abstract
UNLABELLED Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), also termed Hashimoto's encephalopathy (HE), is a rare immune-mediated disorder and is also affecting children and adolescents. It is characterized by altered mental status, seizures, and cognitive dysfunction. Therapeutic options include steroid treatment and prognosis range from complete recovery, a relapsing course to long-term cognitive sequelae. We describe a previously healthy 13-year-old girl presenting to the emergency room with coma and refractory status epilepticus. Generalized tonic-clonic seizures persisted after pre-hospital infusion of antiepileptic medication. She was found to have highly elevated levels of thyroid-stimulating hormone and anti-thyroid peroxidase antibodies not only in blood but also in cerebrospinal fluid while showing negative results for traumatic, infectious, metabolic, toxic, neoplastic, or other known specific autoimmune diseases. Cranial neuroimaging revealed no abnormality. A diagnosis of SREAT was established, and the patient improved rapidly on corticosteroids and levothyroxine therapy. However, 3 months after the discontinuation of steroid treatment, the girl relapsed. The current literature regarding SREAT is reviewed and summarized. CONCLUSION In children with SREAT, early diagnosis and treatment with corticosteroids is crucial and can lead to rapid clinical improvement. Clinicians should be aware of this uncommon but treatable condition, especially in female adolescents with unexplained seizures or an encephalopathic state.
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Mitoma H, Yoneda M, Saitow F, Suzuki H, Matsunaga A, Ikawa M, Mizusawa H. Presynaptic dysfunction caused by cerebrospinal fluid from a patient with the ataxic form of Hashimoto's encephalopathy. ACTA ACUST UNITED AC 2014. [DOI: 10.1111/ncn3.105] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hiroshi Mitoma
- Department of Medical Education; Tokyo Medical University; Tokyo Japan
| | - Makoto Yoneda
- Faculty of Nursing and Social Welfare Science; Fukui Prefectural University; Fukui Japan
| | - Fumihito Saitow
- Department of Pharmacology; Nippon Medical School; Tokyo Japan
| | - Hidenori Suzuki
- Department of Pharmacology; Nippon Medical School; Tokyo Japan
| | - Akiko Matsunaga
- Department of Neurology; University of Fukui Hospital; Fukui Japan
| | - Masamichi Ikawa
- Department of Neurology; University of Fukui Hospital; Fukui Japan
| | - Hidehiro Mizusawa
- Department of Neurology and Neurological Science; Graduate School of Medical and Dental Sciences; Tokyo Medical and Dental University; Tokyo Japan
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Nishida K, Tone K, Yamasaki H, Nishimoto K, Kawamoto K, Futamura N, Mitani M, Funakawa I, Jinnai K. [Case report; a case of Hashimoto's thyroiditis mimicking dementia with Lewy bodies (DLB)]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2014; 103:433-436. [PMID: 24724383 DOI: 10.2169/naika.103.433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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24
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Panda AK, Gopinath G, Maheswari S, Mehta VJ, Bhirud L. Hashimoto's encephalopathy masquerading as chronic meningitis- case of a middle-aged female with review of literature. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2014. [DOI: 10.7713/ijms.2013.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Mercier E. L’encéphalopathie d’Hashimoto en réanimation : quand doit-on l’évoquer ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0729-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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26
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Ishikawa H, Yasui K, Oketa Y, Nomura M, Watanabe T, Mikami H, Suzuki M, Ono S. [Case report: a case of Hashimoto's encephalopathy with myxedema coma]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2013; 102:969-971. [PMID: 23772513 DOI: 10.2169/naika.102.969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Hiroaki Ishikawa
- Department of Neurology, Teikyo University Chba Medical Center, Japan
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Hosoi Y, Kono S, Terada T, Konishi T, Miyajima H. Hashimoto's encephalopathy associated with an elevated intrathecal IgG4 level. J Neurol 2013; 260:1174-6. [PMID: 23471612 DOI: 10.1007/s00415-013-6878-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 01/23/2013] [Accepted: 02/16/2013] [Indexed: 12/24/2022]
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Cognitive impairments in Hashimoto's encephalopathy: a case-control study. PLoS One 2013; 8:e55758. [PMID: 23409036 PMCID: PMC3568150 DOI: 10.1371/journal.pone.0055758] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 12/31/2012] [Indexed: 11/19/2022] Open
Abstract
Background/Aims Hashimoto's encephalopathy is considered as a treatable dementia, but it is often misdiagnosed. We investigated cognitive impairment and the MRI pathology of Hashimoto's encephalopathy patients. Methods The study comprised eight patients with Hashimoto's encephalopathy, 16 patients with mild Alzheimer’s disease and 24 healthy subjects. A neuropsychological battery included assessments of memory, language, attention, executive function and visuospatial ability. Cranial MRI was obtained from all Hashimoto's encephalopathy patients. Results Hashimoto's encephalopathy and mild Alzheimer’s disease showed cognitive impairments in episodic memory, attention, executive function and visuospatial ability, but naming ability was unaffected in Hashimoto's encephalopathy. The MRI of Hashimoto's encephalopathy showed leukoencephalopathy-like type or limbic encephalitis-like type; the lesions did not affect the temporal cortex which plays a role in naming ability. Conclusion Except that the naming ability was retained, the impairments in cognitive functions for the Hashimoto's encephalopathy patients were similar to those of Alzheimer’s disease patients. These results were consistent with the MRI findings.
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Matsunaga A, Ikawa M, Fujii A, Nakamoto Y, Kuriyama M, Yoneda M. Hashimoto's encephalopathy as a treatable adult-onset cerebellar ataxia mimicking spinocerebellar degeneration. Eur Neurol 2012; 69:14-20. [PMID: 23128836 DOI: 10.1159/000342217] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 07/29/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hashimoto's encephalopathy (HE) presents with a variety of neurologic and neuropsychiatric features. In this study, we investigated the clinical and immunological profiles of the cerebellar ataxic form of HE. METHODS The clinical features, treatments, laboratory features, brain imaging, and serum anti-NH(2)-terminal of α-enolase autoantibodies (anti-NAE Abs), a useful diagnostic marker for HE, were investigated in 13 patients who presented with sporadic adult-onset cerebellar ataxia and fulfilled the HE diagnostic criteria (antithyroid Abs and responsiveness to immunotherapy). RESULTS All of the patients presented with truncal ataxia, but nystagmus was uncommon (17%). Eight patients had an insidious onset that mimicked spinocerebellar degeneration (SCD), but brain imaging showed little or no cerebellar atrophy in all of the patients. Those patients with serum anti-NAE Abs (n = 8) did not have nystagmus and tended to respond better to immunotherapy than the anti-NAE Ab-negative patients. CONCLUSION The present study suggests that insidious adult-onset and truncal ataxia are common in the cerebellar ataxic form of HE, which mimics SCD, but that nystagmus and severe cerebellar atrophy are uncommon. Antithyroid and anti-NAE Abs may be useful for diagnosing cerebellar ataxic HE.
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Affiliation(s)
- Akiko Matsunaga
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
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Shimizu F, Kanda T. [Internal medicine and neurological diseases: progress in diagnosis and treatment topics: VIII. Neurological manifestation due to endocrine metabolic disease]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2012; 101:2226-2231. [PMID: 22973694 DOI: 10.2169/naika.101.2226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Fumitaka Shimizu
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan
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Tang Y, Xing Y, Lin MT, Zhang J, Jia J. Hashimoto's encephalopathy cases: Chinese experience. BMC Neurol 2012; 12:60. [PMID: 22827897 PMCID: PMC3439285 DOI: 10.1186/1471-2377-12-60] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 07/10/2012] [Indexed: 01/21/2023] Open
Abstract
Background Hashimoto’s encephalopathy is a poorly understood syndrome consisting of heterogeneous neurological symptoms and high serum antithyroid antibody titers, typically responding to steroids. More clinical series studies are required to characterize the clinical, laboratory and imaging features, and outcomes, especially in the Chinese population. Methods We analyzed the clinical, laboratory, and imaging features and outcomes of thirteen consecutive patients with Hashimoto’s encephalopathy diagnosed in Xuan Wu Hospital, Beijing from 2005 to 2010 retrospectively. Results Cognitive impairment (84.6%) and psychiatric symptoms (38.5%) were the most frequent symptoms. Seizures (30.8%) and myoclonus (7.7%) were less common than previously described. Three (23.1%) patients showed abnormal signals in hippocampus or temporal lobe, which were believed related to their memory disorders or seizures. MRI changes showed resolution paralleling clinical improvement in one patient. Among eight patients who received steroid therapy, five patients recovered, one patient improved with residual deficits, and two patients relapsed or had no effect. Among five non-steroid treated patients, three patients experienced stable remission with antiepileptic drugs or general neurotrophic therapy, and two patients experienced continuous deterioration. Conclusions Most patients with Hashimoto’s encephalopathy showed good response to steroids. Some patients improved without steroid therapy. Considering its reversible course, we recommend that Hashimoto’s encephalopathy should always be in the differential diagnosis while evaluating disorders of the central nervous system.
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Affiliation(s)
- Yi Tang
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, 45 Changchun Street, Beijing 100053, People's Republic of China
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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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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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Casciato S, Di Bonaventura C, Lapenta L, Fattouch J, Ferrazzano G, Fanella M, Di Fabio F, Pasquini M, Amendolea MA, Manfredi M, Prencipe M, Giallonardo AT. Recurrent partial seizures with ictal yawning as atypical presentation of Hashimoto's encephalopathy (steroid-responsive encephalopathy associated with autoimmune thyroiditis). Epilepsy Behav 2011; 22:799-803. [PMID: 22030535 DOI: 10.1016/j.yebeh.2011.09.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 09/15/2011] [Accepted: 09/18/2011] [Indexed: 11/19/2022]
Abstract
Hashimoto's encephalopathy (HE), also known as steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), is a rare condition whose pathogenesis is unknown, though autoimmune-mediated mechanisms are thought to be involved. The prevalent neurological manifestations of this disorder are epileptic seizures and psychocognitive disorders associated with EEG alterations. High anti-thyroid antibody titers (particularly in cerebrospinal fluid) and the effectiveness of steroid therapy are usually considered to be crucial elements in the diagnostic process. We describe a 19-year-old female patient who had been referred to the psychiatric unit because of behavioral disorders characterized predominantly by delirium with sexual content. She developed recurrent focal seizures characterized by atypical ictal semiology (repetitive forceful yawning) and a rare EEG pattern (recurrent seizures arising from the left temporal region without evident "encephalopathic" activity). The presence of anti-thyroperoxidase antibodies in her cerebrospinal fluid and a good response to steroids confirmed the diagnosis of HE. The atypical presentation in the case we describe appears to widen the electroclinical spectrum of HE and highlights its importance for differential diagnosis purposes in the neuropsychiatric setting.
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Affiliation(s)
- S Casciato
- Neurology Unit, Department of Neuroscience, Sapienza University of Rome, Rome, Italy
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Infectious disease or Hashimoto's encephalopathy flares: A case report. Seizure 2011; 20:717-9. [DOI: 10.1016/j.seizure.2011.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Revised: 03/15/2011] [Accepted: 04/22/2011] [Indexed: 11/23/2022] Open
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Mathew V, Misgar RA, Ghosh S, Mukhopadhyay P, Roychowdhury P, Pandit K, Mukhopadhyay S, Chowdhury S. Myxedema coma: a new look into an old crisis. J Thyroid Res 2011; 2011:493462. [PMID: 21941682 PMCID: PMC3175396 DOI: 10.4061/2011/493462] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 05/12/2011] [Indexed: 11/20/2022] Open
Abstract
Myxedema crisis is a severe life threatening form of decompensated hypothyroidism which is associated with a high mortality rate. Infections and discontinuation of thyroid supplements are the major precipitating factors while hypothermia may not play a major role in tropical countries. Low intracellular T3 leads to cardiogenic shock, respiratory depression, hypothermia and coma. Patients are identified on the basis of a low index of suspicion with a careful history and examination focused on features of hypothyroidism and precipitating factors. Arrythmias and coagulation disorders are increasingly being identified in myxedema crisis. Thyroid replacement should be initiated as early as possible with careful attention to hypotension, fluid replacement and steroid replacement in an intensive care facility. Studies have shown that replacement of thyroid hormone through ryles tube with a loading dose and maintenance therapy is as efficacious as intravenous therapy. In many countries T3 is not available and oral therapy with T4 can be used effectively without major significant difference in outcomes. Hypotension, bradycardia at presentation, need for mechanical ventilation, hypothermia unresponsive to treatment, sepsis, intake of sedative drugs, lower GCS and high APACHE II scores and Sequential Organ Failure Assessment (SOFA) scores more than 6 are significant predictors of mortality in myxedema crisis. Early intervention in hypothyroid patients developing sepsis and other precipitating factors and ensuring continued intake of thyroid supplements may prevent mortality and morbidity associated with myxedema crisis.
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Affiliation(s)
- Vivek Mathew
- Institute of Post-Graduate Medical Education & Research, Calcutta 700020, India
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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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Canelo-Aybar C, Loja-Oropeza D, Cuadra-Urteaga J, Romani-Romani F. Hashimoto's encephalopathy presenting with neurocognitive symptoms: a case report. J Med Case Rep 2010; 4:337. [PMID: 20973943 PMCID: PMC2987955 DOI: 10.1186/1752-1947-4-337] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 10/25/2010] [Indexed: 11/29/2022] Open
Abstract
Introduction Hashimoto's encephalopathy is a neurological disorder of unknown cause associated with thyroid autoimmunity. The disease occurs primarily in the fifth decade of life and may present in two types - a sudden vasculitic type or a progressive subacute type associated to cognitive dysfunction, confusion and memory loss. Case presentation We report the case of a 62-year-old Hispanic woman, previously healthy, who developed a subacute onset of declining upper brain function. Serologic studies demonstrated high levels of antithyroid antibodies. Electroencephalographic and magnetic resonance image findings were consistent with Hashimoto's encephalopathy. Conclusion Hashimoto's encephalopathy is a diagnosis of exclusion. This unusual disorder is often under-recognized because of the multiple and protracted neurocognitive manifestations; therefore, it is important to be aware of the clinical manifestations to make a correct diagnosis.
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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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Clinical manifestations, diagnostic criteria and therapy of Hashimoto's encephalopathy: report of two cases. J Neurol Sci 2009; 288:194-6. [PMID: 19846119 DOI: 10.1016/j.jns.2009.09.030] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Revised: 09/23/2009] [Accepted: 09/28/2009] [Indexed: 01/21/2023]
Abstract
Hashimoto's encephalopathy (HE) is a rare, still not well understood, autoimmune disease with neurological and psychiatric manifestations. and elevated titers of antithyroid antibodies in serum and cerebrospinal fluid (CSF) as a hallmark of the disease. Patients are mostly women. Current diagnostic criteria include corticosteroide responsiveness, but it is the case in only 50% of patients with HE. In steroid non-responders other immunomodulatory therapies or plasmapheresis could be applied. Disease course can be acute, subacute, chronic or relapsing-remitting. Two distinct forms emerged from the reported cases: a vasculitic type characterized by multiple relapsing-remitting stroke-like episodes and mild cognitive impairment and a diffuse progressive type characterized by dementia and psychiatric symptoms. Both forms may be accompanied by depressed level of consciousness (stupor or coma), tremor, seizures, or myoclonus. We present two patients with two distinct forms of HE who had different clinical manifestations and response to therapy.
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Acute confusional state caused by Hashimoto's encephalopathy in a patient with hypothyroidism: a case report. CASES JOURNAL 2009; 2:7967. [PMID: 19830030 PMCID: PMC2740226 DOI: 10.4076/1757-1626-2-7967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Accepted: 03/16/2009] [Indexed: 11/29/2022]
Abstract
Introduction Hashimoto's Encephalopathy is an unusual condition associated with Hashimoto's Thyroiditis. This immune-mediated, steroid-dependent entity was first described thirty years ago. In this case report, we discuss the importance of considering this diagnosis in the evaluation of confusion. Case presentation The patient is a 55-year-old African-American woman residing in United States, who was admitted to the hospital with a four-day history of mental status changes. Her past medical history was significant for type II Diabetes Mellitus, Hypertension, and Hypothyroidism. There was no reported seizure activity. The patient's vital signs were stable on admission. On examination, the patient was awake, alert, oriented to place and time. Her neurological examination revealed agraphia and dyslexia. Her speech showed lack of fluency and hesitation. Her complete blood count and electrolytes were within normal limits. The patient's brain CT scan did not reveal any significant findings. Her Magnetic Resonance Imaging only revealed mild chronic microangiopathy, which caused by “small vessel disease.” Her Electroencephalogram did not reveal any finding consistent with seizure activity. Cerebral spinal fluid analysis was likewise did not reveal a cause for this patient's acute onset of confusion. In contrast to the above negative finding, this patient's Thyroid stimulating hormone was discovered to be 15 UIU/ml. She was subsequently given 1000 mg of intravenous Methylprednisolone daily for 3 days. This three-day course of high-dose, intravenous steroids resulted complete resolution of the patient's symptoms. She was then discharged on an eleven-day course of oral prednisone 60 mg. Conclusion Hashimoto's Encephalopathy should be considered in the differential diagnosis of an acute confusional state since it is responsive to steroid therapy and represents a readily reversible cause acute mental status changes. Clues to this diagnosis include elevated antithyroid antibodies, abnormal Thyroid stimulating hormone values, and exclusion of other causes of acute mental status changes.
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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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Abstract
Hashimoto's encephalopathy (HE) is a controversial neurological disorder that comprises a heterogenous group of neurological symptoms that manifest in patients with high titers of antithyroid antibodies. Clinical manifestations of HE may include encephalopathic features such as seizures, behavioral and psychiatric manifestations, movement disorders, and coma. Although it has been linked to cases of Hashimoto's thyroiditis or thyroid dysfunction, the most common immunological feature of HE is the presence of high titers of antithyroglobulin or anti-TPO (antimicrosomal) antibodies. At present, it is unclear whether antithyroid antibodies represent an immune epiphenomenon in a subset of patients with encephalopathic processes or they are really associated with pathogenic mechanisms of the disorder. The significance of classifying encephalopathies under the term HE will be determined in the future once the relevance of the role of antithyroid antibodies is demonstrated or dismissed by more detailed experimental and immunopathological studies. The responsiveness of HE to steroids or other therapies such as plasmapheresis supports the hypothesis that this is a disorder that involves immune pathogenic mechanisms. Further controlled studies of the use of steroids, plasmapheresis, or immunosuppressant medications are needed in the future to prove the concept of the pathogenic role of antithyroid antibodies in HE.
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Affiliation(s)
- Nicoline Schiess
- Department of Neurology, Division of Neuroimmunology and Neuroinfectious Disorders, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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Abstract
Hashimoto's encephalopathy is a term used to describe an encephalopathy of presumed autoimmune origin characterised by high titres of antithyroid peroxidase antibodies. In a similar fashion to autoimmune thyroid disease, Hashimoto's encephalopathy is more common in women than in men. It has been reported in paediatric, adult and elderly populations throughout the world. The clinical presentation may involve a relapsing and remitting course and include seizures, stroke-like episodes, cognitive decline, neuropsychiatric symptoms and myoclonus. Thyroid function is usually clinically and biochemically normal.Hashimoto's encephalopathy appears to be a rare disorder, but, as it is responsive to treatment with corticosteroids, it must be considered in cases of 'investigation negative encephalopathies'. Diagnosis is made in the first instance by excluding other toxic, metabolic and infectious causes of encephalopathy with neuroimaging and CSF examination. Neuroimaging findings are often not helpful in clarifying the diagnosis. Common differential diagnoses when these conditions are excluded are Creutzfeldt-Jakob disease, rapidly progressive dementias, and paraneoplastic and nonparaneoplastic limbic encephalitis. In the context of the typical clinical picture, high titres of antithyroid antibodies, in particular antithyroid peroxidase antibodies, are diagnostic. These antibodies, however, can be detected in elevated titres in the healthy general population. Treatment with corticosteroids is almost always successful, although relapse may occur if this treatment is ceased abruptly. Other forms of immunomodulation, such as intravenous immune-globulin and plasma exchange, may also be effective. Despite the link to autoimmune thyroid disease, the aetiology of Hashimoto's encephalopathy is unknown. It is likely that antithyroid antibodies are not pathogenic, but titres can be a marker of treatment response. Pathological findings can suggest an inflammatory process, but features of a severe vasculitis are often absent. The links between the clinical pictures, thyroid disease, auto-antibody pattern and brain pathology await further clarification through research. It may be that Hashimoto's encephalopathy will be subsumed into a group of nonvasculitic autoimmune inflammatory meningoencephalopathies. This group may include disorders such as limbic encephalitis associated with voltage-gated potassium channel antibodies. Some authors have suggested abandoning any link to Hashimoto and renaming the condition 'steroid responsive encephalopathy associated with autoimmune thyroiditis' to better reflect current, if limited, understanding of this condition.
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Affiliation(s)
- Ramon Mocellin
- Neuropsychiatry Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Abstract
Rapidly progressive dementias (RPDs) are neurologic conditions that develop subacutely over weeks to months or, rarely, acutely over days. In contrast to most dementing conditions that take years to progress to death, RPD quickly can be fatal. It is critical to evaluate patients who have RPD without delay, usually in a hospital setting, as they may have a treatable condition. This review discusses a differential diagnostic approach to RPD, emphasizing neurodegenerative, toxic and metabolic, infectious, autoimmune, neoplastic, and other conditions to consider.
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Affiliation(s)
- Michael D Geschwind
- Department of Neurology, Memory & Aging Center, University of California, San Francisco Medical Center, San Francisco, CA 94117, USA.
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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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Nakamura M, Nakashima I, Sato S, Miyazawa I, Fujihara K, Itoyama Y. Clinical and laboratory features of neuromyelitis optica with oligoclonal IgG bands. Mult Scler 2007; 13:332-5. [PMID: 17439901 DOI: 10.1177/13524585070130030201] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Of 23 neuromyelitis optica (NMO) cases, we found two cases with oligoclonal IgG bands (OBs). Both patients were positive for NMO-IgG. Their common features were long disease duration and co-existing autoimmune diseases (myasthenia gravis and sicca syndrome). Although OBs are mostly negative in NMO, which distinguishes it from multiple sclerosis (MS), they can be positive by long-standing autoimmunity, which may not be directly related to NMO. Multiple Sclerosis 2007; 13: 332-335. http://msj.sagepub.com
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Affiliation(s)
- M Nakamura
- Department of Neurology, Tohoku University School of Medicine, Aoba-ku, Sendai 980-8574, Japan.
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Kang JH, Chang D, Lee YW, Na KJ, Yang MP. Adipsic Hypernatremia in a Dog with Antithyroid Antibodies in Cerebrospinal Fluid and Serum. J Vet Med Sci 2007; 69:751-4. [PMID: 17675808 DOI: 10.1292/jvms.69.751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A 4-year-old, male Labrador retriever, weighing 27 kg, presented with abrupt clinical signs including mental retardation, circling and head pressing. The dog never ingested water by choice. An adipsia of the dog was persisted and developed to hypernatremia with artifactual hyperchloremia. Serial endocrine results and image findings were suggestive of a hypothyroidism. The dog revealed the presence of antithyroid antibodies in the cerebrospinal fluid and serum. With the administration of levothyroxine sodium, his neurologic signs were alleviated within the first week of treatment and adipsia was also resolved.
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Affiliation(s)
- Ji-Houn Kang
- Veterinary Medical Center, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk 361-763, 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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