|LETTER TO THE EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 94-95
A unique presentation of Hashimoto's encephalopathy
Abhishek Juneja, Kuljeet Anand, Arpit Agrawal
Department of Neurology, Dr. RML Hospital, Delhi, India
|Date of Submission||06-Apr-2020|
|Date of Acceptance||10-Jun-2020|
|Date of Web Publication||17-Jul-2020|
Dr. Abhishek Juneja
A-15, Old Quarters, Ramesh Nagar, New Delhi - 110 015
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Juneja A, Anand K, Agrawal A. A unique presentation of Hashimoto's encephalopathy. Thyroid Res Pract 2020;17:94-5
A 54-year-old female patient presented with complaints of slowness of body movements, gait disturbance, and altered behavior. She had altered behavior in the form of loss of interest in surrounding activities and decreased interaction with family members. She was a known case of hypothyroidism for the last 2 years on irregular treatment. There was no history of neuroleptic intake or any other drug known to cause Parkinsonism More Details. On neurological examination, she had hypomimia [Figure 1], hypophonia, and micrographia. She had normal higher mental function on detailed formal testing. She had lead pipe rigidity in all four limbs without any involuntary movements. She had severe bradykinesia with short stepping gait while walking. Rest of the neurological examination was unremarkable. Her routine blood investigations including complete blood count, liver and renal function tests, plasma glucose, serum electrolytes (sodium, potassium, calcium, and magnesium), and ammonia levels were normal. Her thyroid function tests suggested normal serum thyroxin and triiodothyronine levels and elevated serum thyroid-stimulating hormone (TSH) levels (16.8 mIU/L, N: 0.4–4.0 mIU/L). Serum thyroid peroxidase (TPO) antibody levels were also elevated (1380 IU/ml, N <35 IU/ml). Magnetic resonance imaging (MRI) of the brain [Figure 2] and electroencephalography were unremarkable. Her cerebrospinal fluid examination (CSF) examination showed high protein levels (78 mg/dl) without any cellular response. We kept a provisional diagnosis of Hashimoto's encephalopathy (HE) and started the patient on intravenous methylprednisolone at a dose of 1 g/day for 5 days. Her thyroxin replacement therapy was also initiated. The patient improved significantly over the next 2 weeks. Her bradykinesia and rigidity improved. She became more interactive with family members. She was discharged on tapering doses on oral steroids and 100 μg of levothyroxine daily. She later followed up after 6 weeks in the outpatient department. She had completely recovered on follow-up visit with decreasing TSH (11.2 mIU/L) and anti-TPO (360 IU/ml) levels.
|Figure 1: Patient with mask-like facies and slightly forward bent posture|
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|Figure 2: Magnetic resonance imaging brain T1 sequence showing unremarkable features|
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Hypothyroidism may cause various neurological manifestations and complications, involving both central and peripheral nervous system. They include headache, ophthalmoplegia, cognitive impairment, psychosis, encephalopathy, and myopathy including Hoffman's syndrome and peripheral and entrapment neuropathy., HE is a rare neurological complication of autoimmune hypothyroidism. The diagnostic criteria for HE include (a) acute or subacute onset of altered mental status (AMS), (b) elevated antithyroid antibodies, (c) rapid response in mental status with corticosteroids, and (d) absence of structural, infectious, or other metabolic factors, which could explain the AMS and its response to steroids. The pathological mechanism of HE is not entirely clear. Vasculitis has been proposed as a possible mechanism. There have been very few reports of HE presenting as parkinsonism. In our case, the diagnosis of HE was kept based on elevated anti-TPO levels, elevated CSF protein, and dramatic response to steroids. The reason for very few reports of HE presenting as parkinsonism could be that most patients of HE experience consciousness disturbance, thus concealing parkinsonism. We conclude that HE should be kept as differential diagnosis in patients presenting with rapidly progressive symmetric parkinsonism with or without cognitive impairment, considering its treatable nature.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]