Ayşin KISABAY, Kuzeymen BALIKÇI, Serpil SARI, Deniz SELÇUKİ

Manifestation of Hashimoto's encephalopathy with Psychotic Signs: a Case Presentation

Psikotik bulgularla seyreden Hashimoto ensefalopatisi: Olgu sunumu. Hashimoto ensefalopatisi (HE); hashimoto tiroiditi (HT) zemininde gelişen, patofizyolojisi henüz net olmayan, antitiroid antikor ile ilişkili olan, nadir görülen, otoimmün, nöroendokrin ve nöropsikiyatrik bulgularla seyreden bir hastalıktır. EEG'de yaygın veya fokal yavaşlama, serumda antitiroid antikor yüksekliği ve beyin omurilik sıvısında protein yüksekliği, antitiroid antikor varlığı ile karakterizedir. HE merkezi sinir sisteminin otoimmün bozukluğu olarak bilinir. Bu yönüyle hipotiroidizm veya hipertiroidizmde görülen bilişsel değişikliklerden ayrılır. Otoimmün doğası nedeniyle kortikosteroidlere yanıt alınması tanıyı desteklemektedir. Bu yazıda nöropsikiyatrik belirtilerle başvuran ve serumda tiroid antikor titrasyon yüksekliği saptanan ve steroid tedavisine tam olarak yanıt veren bir olgu sunulmuştur. HE tanısı için henüz net bir belirteç bulunmamaktadır. Bu nedenle ayırıcı tanıda bu klinik tabloyu yapabilecek diğer nedenler düşünülmeli ve tetkikler sonrası dışlanmalıdır. Bu olgu; farklı nöropsikiyatrik belirtilerle başvuran hastaların ayırıcı tanısında, oldukça nadir görülen HE tanısının da unutulmaması gerektiğinin ve doğru tanı konulan ve uygun tedavi gören hastalarda tedaviyle gerçekleşen dramatik düzelmenin vurgulanması amacıyla bildirilmiştir.

Psikotik bulgularla seyreden Hashimoto ensefalopatisi: Olgu sunumu

Manifestation of Hashimoto's encephalopathy with psychotic signs: a case presentation. Hashimoto's encephalopathy (HE) is a rare autoimmune disease with unclear pathophysiology, developing on the basis of Hashimoto's thyroiditis (HT), associated with antithyroid antibodies, that presents with autoimmune, neuroendocrine, and neuropsychiatric findings. The disease is characterized by generalized or focal slowing in the EEG, elevated antithyroid antibody titration in the serum, elevated cerebrospinal fluid protein level, and the presence of antithyroid antibodies. HE is known as an autoimmune disorder of the central nervous system. With this feature, it is differentiated from cognitive alterations observed in hypothyroidism or hyperthyroidism. The response to treatment with corticosteroids in line with the autoimmune nature of HE supports this diagnosis. This report shows a case presenting with neuropsychiatric symptoms, elevated antithyroid antibody titration in the serum, and complete response to steroid therapy. A clear indicator for the diagnosis of HE has not yet been found. Therefore, other potential causes need to be considered in the differential diagnosis of this clinical picture until they can be excluded after investigations. With this case report, we want to emphasize that in differential diagnosis of patients presenting with a variety of neuropsychiatric symptoms, Hashimoto's encephalopathy - though being seen quite rarely - should not be disregarded, given the dramatic improvement of patients receiving a correct diagnosis and appropriate treatment.

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Chaudhuri A, Behan PO, The clinical spectrum, diagnosis, pathogenesis and treatment of Hashimoto's encephalopathy (recurrent acute disseminated encephalomyelitis). Curr Med Chem 2003; 10:1945-1953.
Forchetti CM, Katsamakis G, Garron DC. Autoimmune thyroiditis and a rapidly progressive dementia: global hypoperfusion on SPECT scanning suggests a possible mechanism. Neurology 1997; 49:623-626. [CrossRef]
Marshall GA, Doyle JJ, Long-term treatment of Hashimoto's encephalopathy. J Neuropsychiatry Clin Neurosci 2006; 18:14- 20. [CrossRef]
Cantón A, de Fàbregas O, Tintoré M, Mesa J, Codina A, Simó R. Encephalopathy associated to autoimmune thyroid disease: a more appropriate term for an underestimated condition? J Neurol Sci 2000; 176:65-69. [CrossRef]
Brain L, Jellinek EH, Ball K. Hashimoto's disease and encephalopathy. Lancet 1966; 2:512-514. [CrossRef]
Magy L, Vallat JM. Hashimoto's encephalitis. Rev Neurol 2002; 158:966-970.
Cosar B. Endokrin ve Metabolik Bozukluklara Bagli Psikiyatrik Durumlar. Organik Psikiyatri. E Isik (Ed), Ankara: Tayf Matbaası. 1999; 372-374. (Turkish)
Placidi GP, Boldrini M, Patronelli A, Fiore E, Chiovato L, Perugi G, Marazziti D. Prevalence of psychiatric disorders in thyroid diseased patients. Neuropsychobiology 1998; 38:222- 225. [CrossRef]
Baldini IM, Vita A, Mauri MC, Amodei V, Carrisi M, Bravin S, Cantalamessa L. Psychopathological and cognitive features in subclinical hypothyroidism. Prog Neuropsychopharmacol Biol Psychiatry 1997; 21:925-935. [CrossRef]
Jensovsky J, Ruzicka E, Spackova N, Hejdukova B. Changes of event related potential and cognitive processes in patients with subclinical hypothyroidism after thyroxine treatment. Endocr Regul 2002; 36:115-122. [CrossRef]
Asher R. Myxoedematous madness. Br Med J 1949; 2:555-562. [CrossRef]
Bokhari R, Bhatara VS, Bandettini F, McMillin JM. Postpartum psychosis and postpartum thyroiditis. Psychoneuroendocrinology 1998; 23:643-650. [CrossRef]
Ferracci F, Bertiato G, Moretto G. Hashimoto's encephalopathy: epidemiologic data and pathogenetic considerations. J Neurol Sci 2004; 217:165-168. [CrossRef]
Aquino RT, Mutarelli EG. Hashimoto's encephalopathy. Arq Neuropsiquiatr 2009; 67:724-725. [CrossRef]
Kothbauer-Margreiter I, Sturzenegger M, Komor J, Baumgartner R, Hess CW. Encephalopathy associated with Hashimoto thyroiditis: diagnosis and treatment. J Neurol 1996; 243:585-593. [CrossRef]
Ferracci F, Carnevale A. The neurological disorder associated with thyroid autoimmunity. J Neurol 2006; 253:975-984. [CrossRef]
Rolland F, Chevrollier JP. Depression, anti-thyroid antibodies and Hashimoto encephalopathy. Encephale 2001; 27:137-142.
Chong JY, Rowland LP, Utiger RD. Hashimoto encephalopathy: syndrome or myth? Arch Neurol 2003; 60:164-171. [CrossRef]
Archambeaud F, Galinat S, Regouby Y, Magy L, Rebeyrotte I, Vallat JM, Teissier MP. Hashimoto encephalopathy. Analysis of four case reports. Rev Med Interne 2001; 22:653-659. [CrossRef]
Payer J, Petrovic T, Baqi L, Lisy L, Langer P. Hashimoto's encephalopathy and rare cases of hyperthyroidism (review and case report). Endocr Regul 2009; 43:169-178.
Hartmann M, Schaner B, Scheglmann K, Bücking A, Pfister R. Hashimoto encephalopathy: steroid-sensitive encephalopathy in Hashimoto thyroiditis. Nervenarzt 2000; 71:489-494. [CrossRef]
Boers PM, Colebatch JG. Hashimoto's encephalopathy responding to plasmapheresis. J Neurol Neurosurg Psychiatry 2001; 70:132. [CrossRef]
Peschen-Rosin R, Schabet M, Dichgans J. Manifestation of Hashimoto's encephalopathy years before onset of thyroid disease. Eur Neurol 1999; 41:79-84. [CrossRef]
Shaw PJ, Walls TJ, Newman PK, Cleland PG, Cartlidge NE. Hashimoto's encephalopathy: a steroid-responsive disorder associated with high anti-thyroid antibody titers--report of 5 cases. Neurology 1991; 41:228-233. [CrossRef]
Bohnen NI, Parnell KJ, Harper CM. Reversible MRI findings in a patient with Hashimoto's encephalopathy. Neurology 1997; 49:246-247. [CrossRef]