Thyroid
Abstract E-Poster Presentation
Ranim Chamseddin, MD
Internal Medicine Resident
Wayne State University
Auburn Hills, Michigan, United States
Ranim Chamseddin, MD
Internal Medicine Resident
Wayne State University
Auburn Hills, Michigan, United States
Kevser Akyuz
ayah Farfour
Zain Kulairi
Hashimoto’s encephalopathy (HE) is a rare disorder characterized by an autoimmune encephalopathy associated with elevated Thyroid Peroxidase (TPO) antibodies. Clinical features include neurocognitive dysfunction, psychiatric manifestations (paranoia, hallucinations, depression), sleep disturbance, seizures, and transient neurological deficits. The heterogeneity of it’s symptoms, and the broad differential of neuropsychiatric conditions make it a challenging diagnosis. Diagnosis is made in patients with an appropriate clinical picture, elevated TPO antibodies and response to treatment. Only after infectious, toxic and metabolic causes of encephalopathy have been excluded. Treatment includes corticosteroids, Intravenous Immunoglobulins (IVIG), and plasmapheresis.
Case Description :
A 40 year-old female with no past medical history presented with increased anxiety and paranoid thoughts. She felt depressed, had loss of appetite, interest, and trouble sleeping. She was no longer sharp or efficient at work. Her family noted child-like actions and confusion. She was not on any medications. There was no prior psychiatric history. She had Family history of Hashimoto Thyroiditis. She was vitally stable, with an unremarkable exam. Labs showed normal CBC, CMP, TSH, T4, B12, and Vitamin D levels. A urine drug test was negative. Admission and treatment in the psychiatric unit showed no improvement. Psychiatric evaluation revealed an alert and oriented female who had insight about her psychiatric symptoms and was afraid of her cognitive impairment. She had an anxious, and depressed mood. Her memory, reasoning and judgment were impaired. An organic cause was suspected due to the acute presentation, lack of response to medication, and cognitive impairment. A lumbar puncture had normal CSF, EEG showed normal waveforms and MRI of the brain was unremarkable. Anti-NMDA antibodies, and thyroglobulin antibodies were negative, while TPO antibodies were significantly elevated at 903. A thyroid ultrasound revealed diffuse enlargement of thyroid gland. Hashimoto encephalopathy was suspected, and she was given corticosteroids. But due to her poor response, IVIG therapy was started. After 4 days of IVIG therapy she showed improvement, with complete resolution of symptoms during neuropsychiatric evaluation and follow-ups.
Discussion : HE is a reversible cause of encephalopathy unlike many of its resembling conditions. A meta analysis highlights its occurrence in middle aged women. Most cases had normal thyroid function tests, with TPO levels higher than 500, and cognitive impairment/psychiatric manifestations constituted the most common symptoms. Most patients were steroid responsive, with IVIG being second line therapy with good outcomes. Our patients' age, lack of psychiatric history, and poor response to psychiatric medications raised suspicion for an alternate diagnosis. Her work-up and response to treatment confirmed the diagnosis. This illustrates the importance of considering HE in the differential when dealing with unexplained psychiatric and neurocognitive symptoms as it is a readily treatable condition with excellent prognosis.