Review: A Case of Hashimoto’s Encephalopathy

The paper reviewed here is ‘Psychiatric Presentation of Hashimoto’s Encephalopathy’ by Baca-Garcia and colleagues and freely available here. The authors describe the case of a Venezuelan lady who presents to the A&E department at Sao Joao hospital (which is in Portugal and I think has a website here). The team were aware that this lady had a previous history of treated hypothyroidism as well as three prior brief psychotic episodes treated with antipsychotics. She had presented with disorientation, paranoid delusions as well as delta waves on the EEG. The T3 levels were decreased and an antibody screen was undertaken which revealed elevated antithyroglobulin antibodies (Thyroglobulin is a precursor of T3). The researchers found reduced perfusion in the frontal, left temporoparietal and left posterior parietal regions on the SPECT (see the Corepsych blog reviewed here for further discussion on the SPECT). A diagnosis of Hashimoto’s encephalopathy was made and treatment initiated with intravenous methylprednisolone and oral prednisolone with improvement in antibody titres, EEG and psychiatric presentation within a few months. It would have been interesting to see if there were any changes on the SPECT. There were two things the authors wrote which were of interest. The first was speculation on parallels between acute disseminated encephalomyelitis and Hashimoto’s encephalopathy. The second was speculation on the pathological basis of the encephalopathy which they suggested as

1. Vasculitis

2. Direct toxic effects of thyrotropin releasing hormone

3. Local cerebral oedema

The interesting question here is why is the perfusion reduced on the SPECT? If this was repeated and the perfusion had improved in the aforementioned areas then it would be slightly easier to conclude that the perfusion abnormalities were directly related to the pathology. Speculating a little further, if the two are directly related, then it could be argued that a vasculitis would influence perfusion directly as might oedema. Interestingly the authors of another study looking at the neuropsychiatric manifestations of SLE concluded that a combination of MRI and SPECT was better at discriminating neuropsychiatric involvement from non-involvement in SLE on the basis of the imaging findings alone (Castellino et al, 2008). The authors present a rare but important cause of psychosis associated with thyroid pathology.

References

Castellino G, Padovan M, Bortoluzzi A, Borrelli M, Feggi L, Caniatti ML, TrottaF, Govoni M. Rheumatology (Oxford). 2008 Mar;47(3):319-23. Epub 2008 Jan 24. Single photon emission computed tomography and magnetic resonance imagingevaluation in SLE patients with and without neuropsychiatric involvement.

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