Hashimoto's encephalopathy

Myelitis preceding anti-N-terminal of α-enolase antibody-positive Hashimoto's encephalopathy

Hashimoto's encephalopathy is an autoimmune disease characterized by diverse clinical and imaging manifestations, often presenting considerable challenges in its diagnosis, especially when myelitis occurs before the onset of encephalopathy. Anti-N-terminal of α-enolase antibodies targeting the N-terminal of α-enolase are specific serum markers of Hashimoto's encephalopathy; however, studies analyzing their association with myelitis are lacking. Herein, we describe the case of a patient with myelitis who later developed encephalopathy. Owing to positivity for anti-N-terminal of α-enolase antibodies in the serum, a diagnosis of Hashimoto's encephalopathy was made. Detecting anti-NAE antibodies can be useful in diagnosing myelitis of unknown etiology.

The use of intravenous immunoglobulin in the treatment of Hashimoto's encephalopathy: case based review

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.

Hashimoto's Encephalopathy with Use of Intravenous Immunoglobulin as First-Line Therapy

Hashimoto's encephalopathy is an uncommon cause of altered mental status in hospitalized patients and is challenging to diagnose, particularly in the presence of other psychiatric comorbidities. Corticosteroids are the primary treatment. Here, we present a patient with history of post-traumatic stress disorder and prior substance abuse admitted with profound altered mental status and agitation requiring admission to the intensive care unit and mechanical ventilation. He was treated with intravenous immunoglobulin (IVIG) instead of the standard steroid course because of concerns for worsening agitation. The patient had improvement with IVIG infusions, returned to a functional state, and has remained on IVIG therapy monthly since the initial episode without any disease recurrence.

A Rare Case of Hashimoto’s Encephalopathy With Mosaic Turner Syndrome

Mosaicism in Turner syndrome (TS) is a 20%-30% occurrence, with 45, X plus at least another cell line. The haploinsufficiency of the X chromosome is usually responsible for the higher risk of autoimmunity in TS, exhibiting mainly as thyroiditis, type 1 diabetes, etc. Though Hashimoto’s thyroiditis is commonly seen in patients with TS, the concurrence of encephalopathy in these patients is significantly rare and has not been reported. We present a case of a young female with mosaic TS who presented with altered mental status. The initial workup was negative for stroke and pulmonary embolism and cerebrospinal fluid (CSF) analysis did not show any infectious etiology. Thyroid peroxidase (TPO) antibodies (Abs) and thyroglobulin Abs were elevated. As the patient’s mental status deteriorated, there was a concern for Hashimoto’s encephalopathy (HE), hence the patient was started on high-dose IV steroids. Within 24 hours, the patient responded to the IV steroids and an improvement in mentation was noted. HE is a rare immune-mediated disorder, characterized by impaired brain function. The onset of which can be rapid or slowly developing over the course of many years but responds effectively to steroids. Turner syndrome is associated with a high incidence of autoimmune disorders, thus in the setting of a negative workup for more obvious causes, HE should be a consideration when encountered in a clinical scenario.

What Is Different about Teratoma-Associated Anti-LGI1 Encephalitis? A Long-Term Clinical and Neuroimaging Case Series

INTRODUCTION

Anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis is clinically heterogeneous, especially at presentation, and though it is sometimes found in association with tumor, this is by no means the rule.

METHODS

Clinical data for 10 patients with anti-LGI1 encephalitis were collected including one case with teratoma and nine cases without and compared for clinical characteristics. Microscopic pathological examination and immunohistochemical assay of the LGI1 antibody were performed on teratoma tissue obtained by laparoscopic oophorocystectomy.

RESULTS

In our teratoma-associated anti-LGI1 encephalitis case, teratoma pathology was characterized by mostly thyroid tissue and immunohistochemical assay confirmed positive nuclear staining of LGI1 in some tumor cells. The anti-LGl1 patient with teratoma was similar to the non-teratoma cases in many ways: age at onset (average 47.3 in non-teratoma cases); percent presenting with rapidly progressive dementia (67% of non-teratoma cases) and psychiatric symptoms (33%); hyponatremia (78%); normal cerebrospinal fluid results except for positive LGI1 antibody (78%); bilateral hippocampal hyperintensity on magnetic resonance imaging (44%); diffuse slow waves on electroencephalography (33%); good response to immunotherapy (67%); and mild residual cognitive deficit (22%). Her chronic anxiety and presentation with status epilepticus were the biggest differences compared with the non-teratoma cases.

CONCLUSION

In our series, anti-LGI1 encephalitis included common clinical features in our series: rapidly progressive dementia, faciobrachial dystonic seizures, behavioral disorders, hyponatremia, hippocampal hyperintensity on magnetic resonance imaging, and residual cognitive deficit. We observed some differences (chronic anxiety and status epilepticus) in our case with teratoma, but a larger accumulation of cases is needed to improve our knowledge base.

A Case of Euthyroid Steroid-Responsive Encephalopathy With Subacute Dementia

Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), frequently termed as Hashimoto's encephalopathy (HE), is characterized by reversible encephalopathy with the presence of elevated antithyroid antibodies. The condition was initially described due to its association with Hashimoto's thyroiditis. We report a case of euthyroid HE presenting as subacute dementia. A 50-year-old woman presented with progressive memory decline for six weeks. Thyroid function tests, thyroid ultrasound, and cerebrospinal fluid analysis were unremarkable. Electroencephalogram showed generalized slowing with triphasic waves. On magnetic resonance imaging, T1 weighted images revealed hyperintensity in bilateral basal ganglia. Antithyroglobulin and antithyroid peroxidase were markedly elevated. She improved remarkably on tablet prednisolone 60 mg once daily, confirming the suspicion of steroid-responsive encephalopathy. Thus, we conclude that patients with subacute cognitive decline could be screened for antithyroid antibodies in the dementia workup despite their euthyroid status.

Hashimoto's Encephalopathy with Unusual MRI Findings Mimicking Meningoencephalitis: A Case Report and Literature Review

Hashimoto's encephalopathy (HE) is a rare autoimmune disease characterized by a high serum concentration of antithyroid antibodies without evidence of cerebral disease. Magnetic resonance imaging (MRI) findings in HE patients are nonspecific, although diffuse or focal white matter changes have been reported in several cases. We present a rare case involving a 79-year-old woman with elevated antithyroid antibody levels and abnormal imaging findings similar to meningoencephalitis. Serial MRI initially showed multiple T2 hyperintense lesions with diffuse leptomeningeal enhancement that disappeared after steroid therapy.

Neuroimaging of Multiple Sclerosis Mimics

Multiple sclerosis (MS) is the most common immune-mediated disease of the central nervous system, characterized by demyelinating lesions of the brain and the spinal cord. Although it is extremely important to diagnose this condition in a timely manner, to initiate and monitor treatment to prevent permanent neurologic damage and disability, it is also necessary that other demyelinating conditions collectively referred to as MS mimics be identified and excluded. This article describes the in-depth neuroimaging characteristics and morphology of the pathologic lesions on the various neuroimaging modalities.

Hashimoto's encephalopathy mimicking Creutzfeldt-Jakob disease

Hashimoto's encephalopathy is a rare, imprecisely defined autoimmune neurologic syndrome associated with Hashimoto's thyroiditis that normally responds to corticosteroids. Here, we describe the case of a 55-year-old woman who presented with subacute cognitive decline and ataxia. Neoplastic, paraneoplastic, infectious, and metabolic etiologies were ruled out. Anti-TPO antibody level was markedly elevated at 966U/mL. After one month of 60mg/day of oral prednisone, she felt back to baseline and her Montreal Cognitive Assessment dramatically improved. Physicians should strongly consider this uncommon diagnosis in patients with rapid cognitive decline and no other clear etiology.

A case of Hashimoto's encephalopathy misdiagnosed as viral encephalitis

Patient: Male, 61

Final Diagnosis: Hashimoto’s encephalopathy

Symptoms: Neuropsychiatric or neurological manifestations

Medication: Steroids and immunoglobulins

Clinical Procedure: Immunoglobulin combined with corticosteroid therapy

Specialty: Neurology