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CASE REPORT |
From the Departments of Psychiatry (M.A., M.M., R.M., A.S., A.P.P.), Internal Medicine (A.A., P.M.), Nuclear Medicine (A.O., J.G.P.), Neurology (P.A.), Hospital S. João, Alameda Prof Hernani Monteiro, Porto, Portugal; the Department of Psychiatry (M.M.P.-R.), Ramón y Cajal University Hospital, Madrid, Spain; and the Department of Neuroscience (E.B.-G.), Columbia University Medical Center, New York, NY.
Address correspondence and reprint requests to Enrique Baca-Garcia, Department of Neuroscience, Columbia University Medical Center, 1051 Riverside Drive, Suite 2917/unit 42, New York, NY 10032. E-mail: ebacgar2{at}yahoo.es; merperez{at}yahoo.com
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Case report: We present an atypical case of Hashimoto's encephalopathy in a 33-year-old woman who presented with several brief and acute psychotic episodes. After treatment with steroids, there was an improvement in the patient's psychiatric symptoms and electroencephalogram, and antithyroglobulin antibody titers returned to normal levels.
Conclusions: It is our opinion that Hashimoto's encephalopathy should be considered in the differential diagnosis of atypical psychosis, especially because this is a treatable syndrome. This is particularly important in patients with a previous history of thyroid disease, despite current normal thyroid function.
Key Words: Hashimoto's disease • encephalopathy • single-photon emission-computed tomography • psychiatric symptoms
Abbreviations: CT = computed tomography; EEG = electroencephalogram.
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waves. She was treated with antipsychotic drugs and discharged after 1 week, with a diagnosis of brief psychotic disorder.
In August 2004, she suffered a fourth psychotic episode. She began to experience sleep disturbances with total insomnia in the 2 days before hospital admission. In the Emergency Department of St. João Hospital, she presented with perplexity, severe anxiety, and aggressive behavior. During her admission, she suffered from episodes of disorientation, mystic (she believed she was the Virgin Mary) and paranoid delusions, episodes of mutism, depressive mood, and impulsive behavior. The EEG showed slow rhythm with and waves without epileptiform activity and the cerebral CT scan was normal. Complete blood count and biochemistry analyses were normal and serologies (syphilis, human immunodeficiency virus, cytomegalovirus, and herpes virus) were negative. The Wechsler Adult Intelligence Scale demonstrated normal intelligence. The results of the thyroid function tests were in the normal range with the exception of the free T3, which was slightly below the normal range (T3 = 0.94 ng/ml) (reference range 0.60–1.81 ng/ml); free T3 = 2.2 pg/ml (reference range 2.3–4.2 pg/ml); T4 = 9.3 µg/dl (reference range 4.5–10.9 µg/dl); free T4 = 1.34 ng/dl (reference range 0.89–1.80 ng/dl); and TSH = 5.25 µIU/ml (reference range 0.35–5.50 µIU/ml). She was treated with sodium divalproate, risperidone, and diazepam, and she was discharged after 2 weeks.
During ambulatory follow-up, a new EEG showed no improvement. The patient underwent a complete thyroid immunologic study: antinuclear antibodies, antineutrophil cytoplasmic antibodies, thyroid hormones, and antiperoxidase antibodies—all results were normal; antithyroglobulin antibody titers were increased (72 UI/ml).
A hypoechoic image was found in the thyroid ultrasonography and cerebral single-photon emission-computed tomography showed hypoperfusion in multiple areas (Figure 1). The diagnosis of Hashimoto's encephalopathy was made and the patient was referred to the Department of Internal Medicine of S. João Hospital. High doses of intravenous methylprednisolone were prescribed. Later, she began treatment with oral prednisone (60 mg/day) with normalization of antithyroglobulin antibody titers and improvement in both her psychiatric symptoms and her EEG after a few months.
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At that time, the patient's psychotic symptoms had disappeared, and she remained symptom free at the time of her last ambulatory visit (18 months after discharge). The patient had insight into her behavior during the psychotic episode.
Hashimoto's encephalopathy is an unusual entity that is associated with Hashimoto's thyroiditis. It has been described as a syndrome of encephalopathy and high serum antithyroid antibody concentrations that is responsive to glucocorticoid therapy (1). However, there is no evidence that the antibodies have a pathogenic role, but they might be markers of some other autoimmune disorder affecting the brain (1).
The first description of Hashimoto's encephalopathy was made by Brain et al. (2) and, as of 2003, only 105 cases had been reported (1). Myoclonus, epileptic seizures, dementia, and disturbances of consciousness are the most common features (3). Psychotic symptoms are frequent (3).
Although the pathogenesis of the disease remains unclear, several authors have suggested different hypotheses (4). Localized cerebral edema (2), autoimmune vasculitis (3), or a toxic effect of thyrotropin-releasing hormone (5) have been postulated as possible causes. Recently, it has been suggested that the immunopathological basis for this syndrome may be similar to relapsing acute disseminated encephalomyelitis (4).
In summary, this is a case of Hashimoto's encephalopathy with psychotic features: a young woman with previous history of thyroid disease presenting with several brief and acute psychotic episodes (preceded by severe sleep disturbance) and abnormal EEG.
It is our opinion that Hashimoto's encephalopathy should be considered in the differential diagnosis of atypical psychosis, because it is a treatable syndrome (6). This is particularly important in patients with a previous history of thyroid disease, despite current normal thyroid function.
Glenn A. Melvin, PhD, provided editorial assistance.
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DOI:10.1097/PSY.0b013e31803174c0
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