1Department of Pharmacology Faculty of Medicine University of Colombo No 25 Kinsey Road Colombo Sri Lanka2National Hospital of Sri Lanka E W Perera Mawatha Colombo 07 Sri Lanka
Correspondence should be addressed to Chiranthi Kongala Liyanage chiranthiliyanagegmailcom
Received 21 August 2017 Accepted 23 October 2017 Published 6 November 2017
Academic Editor Peter Berlit
Copyright copy 2017 Chiranthi Kongala Liyanage et al This is an open access article distributed under the Creative CommonsAttribution License which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited
Steroid-Responsive Encephalopathy Associated with Autoimmune Thyroiditis (SREAT) is a diagnostic conundrum as it maypresent with a myriad of nonspecific clinical features and laboratory and neuroimaging investigations are not diagnostic Wereport a case of a 65-year-old female who presented with an acute febrile illness associated with headache and confusion tangentialthoughts and loose association Based on neutrophil leukocytosis in the full blood count and elevated inflammatory markers shewas commenced on empirical intravenous antibiotics suspecting meningoencephalitis Further evaluation found a very high titerof both anti-thyroid peroxidase (anti-TPO) antibodies and anti-thyroid globulin antibodies She was clinically and biochemicallyeuthyroid EEG showed right sided frontal intermittent rhythmic delta activity (FIRDA) Cranial MRI revealed age related cerebralatrophy andnonspecific periventricularwhitematter changes A diagnosis of SREATwasmade and shewas treatedwith intravenousmethylprednisolone followed by oral prednisolone Her condition improved dramatically within 48 hours of starting steroidsSREAT is a diagnosis of exclusion in patients with a central nervous system disorder There are no specific clinical features orinvestigative findings Elevated anti-TPO antibodies are considered a hallmark of SREAT and steroid responsiveness supports thediagnosis Prompt diagnosis and treatment reverses the neurological dysfunction in most cases
1 Background
Steroid-Responsive Encephalopathy Associated with Auto-immune Thyroiditis (SREAT) also known as HashimotorsquosEncephalopathy is a rare association with autoimmunethyroid disease [1] Although classified as an autoimmuneencephalitis the pathogenesis of SREAT is still uncertain [12] SREAT has an estimated prevalence of 21 per populationof 100000 [3] There is a female preponderance with casesbeing reported in patients aged 14 to 70 years (average ageof onset 40 to 55 years) [4ndash6] Clinical manifestations ofSREAT are varied and nonspecific [2 5ndash7] Therefore it isoften misdiagnosed or underdiagnosed Due to the lack ofany specific diagnostic investigations SREAT is mainly adiagnosis of exclusion to be considered in the setting ofencephalopathy with high anti-TPO-Ab titers and respon-siveness to glucocorticoid therapy
We report a case of SREAT diagnosed in a 65-year-old female who was clinically euthyroid presenting withbehavior changes and neuropsychiatric manifestations withan acute febrile illness
2 Case History
A 65-year-old female with diabetes hypertension and ontreatment for hypothyroidism presented to the NationalHospital of Sri Lanka with a history of fever and headache forthree days and progressively worsening confusion She alsogave a history of on and off giddiness and lightheadednessparticularly during standing from supine or seated positionsThe family members had noted that she had become increas-ingly withdrawn and has had episodic confusion She did nothave any respiratory or gastrointestinal symptoms
HindawiCase Reports in Neurological MedicineVolume 2017 Article ID 3790741 4 pageshttpsdoiorg10115520173790741
2 Case Reports in Neurological Medicine
She has been on treatment for type 2 diabetes mellitusand hypertension for ten years and for hypothyroidism for3 years She also had stable chronic kidney disease (stage III)Shewas onmetformin gliclazide losartan and levothyroxinewith good compliance to therapy with a regular medicalclinic follow-upThere was no prior history of any psychiatricillnesses or substance abuse There was no family history ofsimilar illnesses either
During the hospital stay she had intermittent fever spikeswith temperature varying between 37∘C and 39∘C Her bloodpressure was 17090mmHg on admission and there was nopostural drop in blood pressure Mental state examinationrevealed a depressedmood loose associations and tangentialthoughts However she did not have any hallucination ordelusions Mini-Mental State Examination Score was 25There was no suicidal or homicidal ideation Her GlasgowComa Score (GCS) was 1415 There was no neck stiffness orfocal neurological deficitsThe rest of the system examinationwas unremarkable Funduscopic examination revealed grade2 hypertensive retinopathy
Her initial laboratory investigations revealed a total whiteblood count of 15times 103 with 85 neutrophils ESRwas 65mmin the 1st hour and CRP was 255mgl With the presenceof confusion and neuropsychiatric manifestations in thesetting of an acute febrile illness intravenous ceftriaxone andacyclovir were commenced suspecting meningoencephalitis
However her cerebrospinal fluid (CSF) analysis revealedonly two lymphocytes per mm3 with normal protein andsugar levels The electroencephalogram (EEG) showed dif-fused background attenuation and right sided frontal inter-mittent rhythmic delta activity (FIRDA) The MRI brainshowed prominent sulci and gyri with age related atrophyand periventricular white matter ischemic changes Herfree T4 was 124 ngdL (089ndash176) and thyroid stimulatinghormone (TSH) level was 057mIUL (055ndash478) She hada substantially high titer of anti-TPO (over 1000 IUml) andanti-thyroglobulin (24719 IUml) antibodies The thyroidultrasound scan did not show any inflammation of the gland
Serum creatinine was stable at approximately 140 to160mmoll and serum electrolytes including sodium potas-sium ionized calcium and phosphate were normal through-out the hospital stay Aspartate aminotransferase (AST) was148UL and alanine aminotransferase (ALT) was 132ULHer ultrasound abdomen showed loss of corticomedullarydemarcation in normal sized kidneys and a normal liverThe other liver function tests were normal All other bloodinvestigations including antinuclear antibody titer and sero-logical tests for herpes simplex virus (HSV) cytomegalovirushuman immunodeficiency virus (HIV) viral hepatitis B viralhepatitis C and syphilis were negative Her cerebrospinalfluid (CSF) gram stain pyogenic cultures herpes simplexvirus (HSV) PCR (Multiplex-Real-Time Assay) and cytologywere negative Blood and urine pyogenic cultures did notreveal any growth
There was inadequate clinical response to antibiotic andantiviral therapy Other infectious inflammatory and malig-nant causes were excluded In the presence of high thyroidautoantibodies a diagnosis of SREAT was made She wasgiven intravenousmethylprednisolone 1 g daily for 3 days and
then started on oral prednisolone 1mg per kilogram (60mg)daily She showed a dramatic improvement to methylpred-nisolone pulses within 48 hours her temperature returnedto normal and her disorientation and thought disordersresolved Prednisolone was gradually tapered over a four-month period without any relapse of symptoms
3 Discussion
Since the first description of SREAT in 1966 [8] the clinicalspectrum of the disease has expanded due to reporting ofmore cases with varying presentations Majority of cases ofSREAT run a fluctuating course with features such as cogni-tive impairment [9] seizures including status epilepticus [10]and myoclonus tremor ataxia sleep disturbance headache[11] depression or psychosis [1 2 4 5 11ndash13] Occurrence offocal neurological deficits has been described as well [8 14]Recently it has drawn much interest as a reversible cause ofdementia [15 16] Although SREAT commonly presents asa slowly progressive disease more acute presentation withstroke-like episodes have also been described [17 18] Ourpatient presented with an acute febrile illness associated withheadache confusion depressed mood and subtle featuresof a thought disorder SREAT presenting with an acutefebrile illness and neuropsychiatric manifestations similar toour patient have been described in a few case reports [19ndash21] Although some of these cases are undisputable acutepresentations some may have had symptoms for a periodof time and may have sought medical attention due to aconcomitant febrile illness [22]
Disease manifestations of SREAT occur independent ofthe thyroid status [1] Our patient was clinically and bio-chemically euthyroid while being on levothyroxine therapyAlthough most cases are usually euthyroid SREAT hasbeen reported in cases with overt hyperthyroidism to overthypothyroidism [5 7] High titers of anti-TPO-Ab are foundin nearly all reported cases [5 6 12 23] and it is considered tobe a hallmark of the disease However its role in pathogenesisof SREAT is still uncertain [2] Elevated anti-thyroglobulinantibodies are found in 60ndash45 of cases [5 12 21] Ourpatient had very high titers of both antibodies which is notdiagnostic but considerably favors the diagnosis of SREATin the clinical context of the patient However as noted byFerracci et al [24] and Ilias et al [25] measurement of CSFanti-thyroid antibodies titers may be a more reliable markeras intrathecal synthesis of these antibodies is postulatedAlthough the lack of anti-thyroid antibody determination inCSF is a limitation in this study the rapid response to steroidsleaves very little doubt about the diagnosis
All laboratory investigation findings in SREAT are non-specific Like in our patient 38ndash50 have elevated livertransaminases and some may have elevated inflammatorymarkers [5 6 12] CSF analysis may show elevated proteins innearly 60 of cases Rarely it can be positive for oligoclonalbands [5 6 12] Moreover EEG findings are nondescriptwith generalized slowing seen in majority of cases [7 12]Nonspecific abnormal signals in white matter or normalfindings are seen in most of the patients on cranial MRI[5 7 12] The diagnosis of SREAT in our patient was based
Case Reports in Neurological Medicine 3
on the clinical context and very high titers of anti-thyroidantibodies in the absence of any other causes to accountfor the manifestations However as no diagnostic tests ordefinitive criteria for diagnosis of SREAT are available ourdiagnosis remains hypothetical
To date there are no accepted guidelines on treatmentof SREAT Therapeutic options used include intravenousor oral steroids [2 4 5 17] immune modulators suchas azathioprine [14] methotrexate cyclophosphamide andintravenous immunoglobulin [12] Our patient showed adramatic improvement following intravenous steroid therapyThis has been described as a typical clinical characteristic ofSREAT [1 2 5 6 8]Though there is no consensus onwhethersteroid responsiveness can be used as a diagnostic criterionof SREAT a beneficial response to steroids remains a strongindication of autoimmunity in the pathogenesis of SREAT
In conclusion clinicians should have a high degree ofclinical suspicion of SREAT as it may manifest as a myriadof clinical presentations The diagnosis is primarily basedon exclusion of other infective inflammatory autoimmuneand neoplastic etiologies in the presence of high anti-TPOandor anti-thyroglobulin antibodies Steroid responsivenessfurther reinforces the diagnosis Given the reversibility ofclinical manifestations SREAT should be in the differentialdiagnosis when evaluating central nervous system disordersand treatment with steroids should not be delayed if thediagnosis is considered
activityg GramGCS Glasgow Coma ScoreHE Hashimotorsquos encephalopathyHSV Herpes simplex virusIUml International units per millilitermg Milligrammgl Milligram per litermm MillimetermmHg Millimeters mercurymmoll Millimole per literMRI Magnetic resonant imagingPCR Polymerase chain reactionSREAT Steroid-Responsive Encephalopathy
Associated with AutoimmuneThyroiditisT4 ThyroxineTSH Thyroid stimulating hormoneUL Units per liter
Conflicts of Interest
The authors declare that there are no conflicts of interestregarding the publication of this article
Authorsrsquo Contributions
All the authors were involved in patient management andcare The article was written by Chiranthi Kongala LiyanageTilak Manthi Janake Munasinghe and Adsareswary Para-manantham have made contributions to the analysis andinterpretation of data and have been involved in revisingthe manuscript All authors have given final approval of theversion to be published
References
[1] J Y Chong L P Rowland and R D Utiger ldquoHashimotoencephalopathy syndrome ormythrdquo JAMANeurology vol 60no 2 pp 164ndash171 2003
[2] J Payer T Petrovic L Lisy and P Langer ldquoHashimotoencephalopathy a rare intricate syndromerdquo International Jour-nal of Endocrinology andMetabolism vol 10 no 2 pp 506ndash5142012
[3] F Ferracci G Bertiato and G Moretto ldquoHashimotorsquosencephalopathy epidemiologic data and pathogeneticconsiderationsrdquo Journal of the Neurological Sciences vol217 no 2 pp 165ndash168 2004
[4] F H Mahmud A N Lteif D L Renaud A M Reed and CK Brands ldquoSteroid-responsive encephalopathy associated withHashimotorsquos thyroiditis in an adolescent with chronic halluci-nations and depression case report and reviewrdquo Pediatrics vol112 no 3 pp 686ndash690 2003
[5] Y Tang Y Xing M T Lin J Zhang and J Jia ldquoHashimotorsquosencephalopathy cases Chinese experiencerdquo BMC Neurologyvol 12 article 60 2012
[6] PM S SharmaM Javali RMahale B KMadhusudhan A AMajeed and R Srinivasa ldquoHashimoto encephalopathy A studyof the clinical profile radiological and electrophysiologicalcorrelation in a Tertiary Care Center in South Indiardquo Journal ofNeurosciences in Rural Practice vol 6 no 3 pp 309ndash314 2015
[7] C Laurent J Capron B Quillerou et al ldquoSteroid-responsiveencephalopathy associated with autoimmune thyroiditis(SREAT) Characteristics treatment and outcome in 251 casesfrom the literaturerdquo Autoimmunity Reviews vol 15 no 12 pp1129ndash1133 2016
[8] L Brain E H Jellinek and K Ball ldquoHashimotorsquos disease andencephalopathyrdquoThe Lancet vol 2 no 7462 pp 512ndash514 1966
[9] J Wang J Zhang L Xu et al ldquoCognitive impairments inhashimotorsquos encephalopathy a case-control studyrdquo PLoS ONEvol 8 no 2 article e55758 2013
[10] M Al-Busaidi J Burad A Al-Belushi and A Gujjar ldquoSuperrefractory status epilepticus in hashimotorsquos encephalopathyrdquoOman Medical Journal vol 32 no 3 pp 247ndash250 2017
[11] I Correia I B Marques R Ferreira and L Sousa ldquoEnceph-alopathy associated with autoimmune thyroid disease a poten-tially reversible conditionrdquo Case Reports in Medicine vol 2016Article ID 9183979 6 pages 2016
[12] P Castillo B Woodruff R Caselli et al ldquoSteroid-responsiveencephalopathy associated with autoimmune thyroiditisrdquoJAMA Neurology vol 63 no 2 pp 197ndash202 2006
[13] L Lalanne M-E Meriot E Ruppert M-A ZimmermannJ-M Danion and P Vidailhet ldquoAttempted infanticide andsuicide inaugurating catatonia associated with Hashimotorsquosencephalopathy A case reportrdquo BMC Psychiatry vol 16 no 1article 13 2016
4 Case Reports in Neurological Medicine
[14] AAlazzeh S JaroudiMGooch andAN Peiris ldquoFocal neuro-logical presentation in Hashimotorsquos encephalopathy mimickinga vascular occlusion of the middle cerebral arteryrdquo BMJ CaseReports article 219933 2017
[15] KAnand J Garg RVerma andAChakraborty ldquoHashimoto1015840sencephalitis unusual cause of reversible dementiardquo Journal ofFamily Medicine and Primary Care vol 3 no 3 pp 284ndash2862014
[16] T Chang M T M Riffsy and P S Gunaratne ldquoHashimotoencephalopathy Clinical and MRI improvement followinghigh-dose corticosteroid therapyrdquo The Neurologist vol 16 no6 pp 394ndash396 2010
[17] E Bonmann M Prumbaum C Stippich P Ringleb and USliwka ldquoHashimoto encephalopathy rare cause of stroke inyoung patientrdquoTheNeurologist vol 15 no 6 pp 342ndash344 2009
[18] B R Graham N Shiff M Nour S Hasal R Huntsman andS Almubarak ldquoHashimoto encephalopathy presenting withstroke-like episodes in an adolescent female a case report andliterature reviewrdquo Pediatric Neurology vol 59 pp 62ndash70 2016
[19] A Shindo Y Ii R Sasaki Y Takahashi M Yoneda and SKuzuhara ldquoNon-herpetic acute limbic encephalitis-like mani-festation in a case of Hashimotorsquos encephalopathy with positiveautoantibodies against ionotropic glutamate receptor 1205762rdquo Jour-nal of Clinical Neurology vol 47 no 10 pp 629ndash634 2007
[20] M-J Lee H-S Lee J-S Hwang and D-E Jung ldquoA caseof Hashimotorsquos encephalopathy presenting with seizures andpsychosisrdquo Korean Journal of Pediatrics vol 55 no 3 pp 111ndash113 2012
[21] T Lu Z Zhou A Wu B Qin and Z Lu ldquoFebrile Hashimotorsquosencephalopathy associated withHashitoxicosisrdquoActa Neurolog-ica Belgica vol 115 no 4 pp 811ndash813 2015
[22] R T R De Aquino and E G Mutarelli ldquoHashimotorsquos enceph-alopathyrdquo Arquivos de Neuro-Psiquiatria vol 67 no 3 A pp724-725 2009
[23] R Mocellin M Walterfang and D Velakoulis ldquoHashimotorsquosencephalopathy epidemiology pathogenesis and manage-mentrdquo CNS Drugs vol 21 no 10 pp 799ndash811 2007
[24] F Ferracci GMoretto RM Candeago et al ldquoAntithyroid anti-bodies in the CSF their role in the pathogenesis of Hashimotorsquosencephalopathyrdquo Neurology vol 60 no 4 pp 712ndash714 2003
[25] I Ilias V Karagiorga G Paraskevas et al ldquoThyroid autoanti-bodies in the cerebrospinal fluid of subjects with and withoutthyroid disease Implications for Hashimotorsquos encephalopathyrdquoJournal ofThyroid Research vol 2015 Article ID 819072 4 pages2015
She has been on treatment for type 2 diabetes mellitusand hypertension for ten years and for hypothyroidism for3 years She also had stable chronic kidney disease (stage III)Shewas onmetformin gliclazide losartan and levothyroxinewith good compliance to therapy with a regular medicalclinic follow-upThere was no prior history of any psychiatricillnesses or substance abuse There was no family history ofsimilar illnesses either
During the hospital stay she had intermittent fever spikeswith temperature varying between 37∘C and 39∘C Her bloodpressure was 17090mmHg on admission and there was nopostural drop in blood pressure Mental state examinationrevealed a depressedmood loose associations and tangentialthoughts However she did not have any hallucination ordelusions Mini-Mental State Examination Score was 25There was no suicidal or homicidal ideation Her GlasgowComa Score (GCS) was 1415 There was no neck stiffness orfocal neurological deficitsThe rest of the system examinationwas unremarkable Funduscopic examination revealed grade2 hypertensive retinopathy
Her initial laboratory investigations revealed a total whiteblood count of 15times 103 with 85 neutrophils ESRwas 65mmin the 1st hour and CRP was 255mgl With the presenceof confusion and neuropsychiatric manifestations in thesetting of an acute febrile illness intravenous ceftriaxone andacyclovir were commenced suspecting meningoencephalitis
However her cerebrospinal fluid (CSF) analysis revealedonly two lymphocytes per mm3 with normal protein andsugar levels The electroencephalogram (EEG) showed dif-fused background attenuation and right sided frontal inter-mittent rhythmic delta activity (FIRDA) The MRI brainshowed prominent sulci and gyri with age related atrophyand periventricular white matter ischemic changes Herfree T4 was 124 ngdL (089ndash176) and thyroid stimulatinghormone (TSH) level was 057mIUL (055ndash478) She hada substantially high titer of anti-TPO (over 1000 IUml) andanti-thyroglobulin (24719 IUml) antibodies The thyroidultrasound scan did not show any inflammation of the gland
Serum creatinine was stable at approximately 140 to160mmoll and serum electrolytes including sodium potas-sium ionized calcium and phosphate were normal through-out the hospital stay Aspartate aminotransferase (AST) was148UL and alanine aminotransferase (ALT) was 132ULHer ultrasound abdomen showed loss of corticomedullarydemarcation in normal sized kidneys and a normal liverThe other liver function tests were normal All other bloodinvestigations including antinuclear antibody titer and sero-logical tests for herpes simplex virus (HSV) cytomegalovirushuman immunodeficiency virus (HIV) viral hepatitis B viralhepatitis C and syphilis were negative Her cerebrospinalfluid (CSF) gram stain pyogenic cultures herpes simplexvirus (HSV) PCR (Multiplex-Real-Time Assay) and cytologywere negative Blood and urine pyogenic cultures did notreveal any growth
There was inadequate clinical response to antibiotic andantiviral therapy Other infectious inflammatory and malig-nant causes were excluded In the presence of high thyroidautoantibodies a diagnosis of SREAT was made She wasgiven intravenousmethylprednisolone 1 g daily for 3 days and
then started on oral prednisolone 1mg per kilogram (60mg)daily She showed a dramatic improvement to methylpred-nisolone pulses within 48 hours her temperature returnedto normal and her disorientation and thought disordersresolved Prednisolone was gradually tapered over a four-month period without any relapse of symptoms
3 Discussion
Since the first description of SREAT in 1966 [8] the clinicalspectrum of the disease has expanded due to reporting ofmore cases with varying presentations Majority of cases ofSREAT run a fluctuating course with features such as cogni-tive impairment [9] seizures including status epilepticus [10]and myoclonus tremor ataxia sleep disturbance headache[11] depression or psychosis [1 2 4 5 11ndash13] Occurrence offocal neurological deficits has been described as well [8 14]Recently it has drawn much interest as a reversible cause ofdementia [15 16] Although SREAT commonly presents asa slowly progressive disease more acute presentation withstroke-like episodes have also been described [17 18] Ourpatient presented with an acute febrile illness associated withheadache confusion depressed mood and subtle featuresof a thought disorder SREAT presenting with an acutefebrile illness and neuropsychiatric manifestations similar toour patient have been described in a few case reports [19ndash21] Although some of these cases are undisputable acutepresentations some may have had symptoms for a periodof time and may have sought medical attention due to aconcomitant febrile illness [22]
Disease manifestations of SREAT occur independent ofthe thyroid status [1] Our patient was clinically and bio-chemically euthyroid while being on levothyroxine therapyAlthough most cases are usually euthyroid SREAT hasbeen reported in cases with overt hyperthyroidism to overthypothyroidism [5 7] High titers of anti-TPO-Ab are foundin nearly all reported cases [5 6 12 23] and it is considered tobe a hallmark of the disease However its role in pathogenesisof SREAT is still uncertain [2] Elevated anti-thyroglobulinantibodies are found in 60ndash45 of cases [5 12 21] Ourpatient had very high titers of both antibodies which is notdiagnostic but considerably favors the diagnosis of SREATin the clinical context of the patient However as noted byFerracci et al [24] and Ilias et al [25] measurement of CSFanti-thyroid antibodies titers may be a more reliable markeras intrathecal synthesis of these antibodies is postulatedAlthough the lack of anti-thyroid antibody determination inCSF is a limitation in this study the rapid response to steroidsleaves very little doubt about the diagnosis
All laboratory investigation findings in SREAT are non-specific Like in our patient 38ndash50 have elevated livertransaminases and some may have elevated inflammatorymarkers [5 6 12] CSF analysis may show elevated proteins innearly 60 of cases Rarely it can be positive for oligoclonalbands [5 6 12] Moreover EEG findings are nondescriptwith generalized slowing seen in majority of cases [7 12]Nonspecific abnormal signals in white matter or normalfindings are seen in most of the patients on cranial MRI[5 7 12] The diagnosis of SREAT in our patient was based
Case Reports in Neurological Medicine 3
on the clinical context and very high titers of anti-thyroidantibodies in the absence of any other causes to accountfor the manifestations However as no diagnostic tests ordefinitive criteria for diagnosis of SREAT are available ourdiagnosis remains hypothetical
To date there are no accepted guidelines on treatmentof SREAT Therapeutic options used include intravenousor oral steroids [2 4 5 17] immune modulators suchas azathioprine [14] methotrexate cyclophosphamide andintravenous immunoglobulin [12] Our patient showed adramatic improvement following intravenous steroid therapyThis has been described as a typical clinical characteristic ofSREAT [1 2 5 6 8]Though there is no consensus onwhethersteroid responsiveness can be used as a diagnostic criterionof SREAT a beneficial response to steroids remains a strongindication of autoimmunity in the pathogenesis of SREAT
In conclusion clinicians should have a high degree ofclinical suspicion of SREAT as it may manifest as a myriadof clinical presentations The diagnosis is primarily basedon exclusion of other infective inflammatory autoimmuneand neoplastic etiologies in the presence of high anti-TPOandor anti-thyroglobulin antibodies Steroid responsivenessfurther reinforces the diagnosis Given the reversibility ofclinical manifestations SREAT should be in the differentialdiagnosis when evaluating central nervous system disordersand treatment with steroids should not be delayed if thediagnosis is considered
activityg GramGCS Glasgow Coma ScoreHE Hashimotorsquos encephalopathyHSV Herpes simplex virusIUml International units per millilitermg Milligrammgl Milligram per litermm MillimetermmHg Millimeters mercurymmoll Millimole per literMRI Magnetic resonant imagingPCR Polymerase chain reactionSREAT Steroid-Responsive Encephalopathy
Associated with AutoimmuneThyroiditisT4 ThyroxineTSH Thyroid stimulating hormoneUL Units per liter
Conflicts of Interest
The authors declare that there are no conflicts of interestregarding the publication of this article
Authorsrsquo Contributions
All the authors were involved in patient management andcare The article was written by Chiranthi Kongala LiyanageTilak Manthi Janake Munasinghe and Adsareswary Para-manantham have made contributions to the analysis andinterpretation of data and have been involved in revisingthe manuscript All authors have given final approval of theversion to be published
References
[1] J Y Chong L P Rowland and R D Utiger ldquoHashimotoencephalopathy syndrome ormythrdquo JAMANeurology vol 60no 2 pp 164ndash171 2003
[2] J Payer T Petrovic L Lisy and P Langer ldquoHashimotoencephalopathy a rare intricate syndromerdquo International Jour-nal of Endocrinology andMetabolism vol 10 no 2 pp 506ndash5142012
[3] F Ferracci G Bertiato and G Moretto ldquoHashimotorsquosencephalopathy epidemiologic data and pathogeneticconsiderationsrdquo Journal of the Neurological Sciences vol217 no 2 pp 165ndash168 2004
[4] F H Mahmud A N Lteif D L Renaud A M Reed and CK Brands ldquoSteroid-responsive encephalopathy associated withHashimotorsquos thyroiditis in an adolescent with chronic halluci-nations and depression case report and reviewrdquo Pediatrics vol112 no 3 pp 686ndash690 2003
[5] Y Tang Y Xing M T Lin J Zhang and J Jia ldquoHashimotorsquosencephalopathy cases Chinese experiencerdquo BMC Neurologyvol 12 article 60 2012
[6] PM S SharmaM Javali RMahale B KMadhusudhan A AMajeed and R Srinivasa ldquoHashimoto encephalopathy A studyof the clinical profile radiological and electrophysiologicalcorrelation in a Tertiary Care Center in South Indiardquo Journal ofNeurosciences in Rural Practice vol 6 no 3 pp 309ndash314 2015
[7] C Laurent J Capron B Quillerou et al ldquoSteroid-responsiveencephalopathy associated with autoimmune thyroiditis(SREAT) Characteristics treatment and outcome in 251 casesfrom the literaturerdquo Autoimmunity Reviews vol 15 no 12 pp1129ndash1133 2016
[8] L Brain E H Jellinek and K Ball ldquoHashimotorsquos disease andencephalopathyrdquoThe Lancet vol 2 no 7462 pp 512ndash514 1966
[9] J Wang J Zhang L Xu et al ldquoCognitive impairments inhashimotorsquos encephalopathy a case-control studyrdquo PLoS ONEvol 8 no 2 article e55758 2013
[10] M Al-Busaidi J Burad A Al-Belushi and A Gujjar ldquoSuperrefractory status epilepticus in hashimotorsquos encephalopathyrdquoOman Medical Journal vol 32 no 3 pp 247ndash250 2017
[11] I Correia I B Marques R Ferreira and L Sousa ldquoEnceph-alopathy associated with autoimmune thyroid disease a poten-tially reversible conditionrdquo Case Reports in Medicine vol 2016Article ID 9183979 6 pages 2016
[12] P Castillo B Woodruff R Caselli et al ldquoSteroid-responsiveencephalopathy associated with autoimmune thyroiditisrdquoJAMA Neurology vol 63 no 2 pp 197ndash202 2006
[13] L Lalanne M-E Meriot E Ruppert M-A ZimmermannJ-M Danion and P Vidailhet ldquoAttempted infanticide andsuicide inaugurating catatonia associated with Hashimotorsquosencephalopathy A case reportrdquo BMC Psychiatry vol 16 no 1article 13 2016
4 Case Reports in Neurological Medicine
[14] AAlazzeh S JaroudiMGooch andAN Peiris ldquoFocal neuro-logical presentation in Hashimotorsquos encephalopathy mimickinga vascular occlusion of the middle cerebral arteryrdquo BMJ CaseReports article 219933 2017
[15] KAnand J Garg RVerma andAChakraborty ldquoHashimoto1015840sencephalitis unusual cause of reversible dementiardquo Journal ofFamily Medicine and Primary Care vol 3 no 3 pp 284ndash2862014
[16] T Chang M T M Riffsy and P S Gunaratne ldquoHashimotoencephalopathy Clinical and MRI improvement followinghigh-dose corticosteroid therapyrdquo The Neurologist vol 16 no6 pp 394ndash396 2010
[17] E Bonmann M Prumbaum C Stippich P Ringleb and USliwka ldquoHashimoto encephalopathy rare cause of stroke inyoung patientrdquoTheNeurologist vol 15 no 6 pp 342ndash344 2009
[18] B R Graham N Shiff M Nour S Hasal R Huntsman andS Almubarak ldquoHashimoto encephalopathy presenting withstroke-like episodes in an adolescent female a case report andliterature reviewrdquo Pediatric Neurology vol 59 pp 62ndash70 2016
[19] A Shindo Y Ii R Sasaki Y Takahashi M Yoneda and SKuzuhara ldquoNon-herpetic acute limbic encephalitis-like mani-festation in a case of Hashimotorsquos encephalopathy with positiveautoantibodies against ionotropic glutamate receptor 1205762rdquo Jour-nal of Clinical Neurology vol 47 no 10 pp 629ndash634 2007
[20] M-J Lee H-S Lee J-S Hwang and D-E Jung ldquoA caseof Hashimotorsquos encephalopathy presenting with seizures andpsychosisrdquo Korean Journal of Pediatrics vol 55 no 3 pp 111ndash113 2012
[21] T Lu Z Zhou A Wu B Qin and Z Lu ldquoFebrile Hashimotorsquosencephalopathy associated withHashitoxicosisrdquoActa Neurolog-ica Belgica vol 115 no 4 pp 811ndash813 2015
[22] R T R De Aquino and E G Mutarelli ldquoHashimotorsquos enceph-alopathyrdquo Arquivos de Neuro-Psiquiatria vol 67 no 3 A pp724-725 2009
[23] R Mocellin M Walterfang and D Velakoulis ldquoHashimotorsquosencephalopathy epidemiology pathogenesis and manage-mentrdquo CNS Drugs vol 21 no 10 pp 799ndash811 2007
[24] F Ferracci GMoretto RM Candeago et al ldquoAntithyroid anti-bodies in the CSF their role in the pathogenesis of Hashimotorsquosencephalopathyrdquo Neurology vol 60 no 4 pp 712ndash714 2003
[25] I Ilias V Karagiorga G Paraskevas et al ldquoThyroid autoanti-bodies in the cerebrospinal fluid of subjects with and withoutthyroid disease Implications for Hashimotorsquos encephalopathyrdquoJournal ofThyroid Research vol 2015 Article ID 819072 4 pages2015
on the clinical context and very high titers of anti-thyroidantibodies in the absence of any other causes to accountfor the manifestations However as no diagnostic tests ordefinitive criteria for diagnosis of SREAT are available ourdiagnosis remains hypothetical
To date there are no accepted guidelines on treatmentof SREAT Therapeutic options used include intravenousor oral steroids [2 4 5 17] immune modulators suchas azathioprine [14] methotrexate cyclophosphamide andintravenous immunoglobulin [12] Our patient showed adramatic improvement following intravenous steroid therapyThis has been described as a typical clinical characteristic ofSREAT [1 2 5 6 8]Though there is no consensus onwhethersteroid responsiveness can be used as a diagnostic criterionof SREAT a beneficial response to steroids remains a strongindication of autoimmunity in the pathogenesis of SREAT
In conclusion clinicians should have a high degree ofclinical suspicion of SREAT as it may manifest as a myriadof clinical presentations The diagnosis is primarily basedon exclusion of other infective inflammatory autoimmuneand neoplastic etiologies in the presence of high anti-TPOandor anti-thyroglobulin antibodies Steroid responsivenessfurther reinforces the diagnosis Given the reversibility ofclinical manifestations SREAT should be in the differentialdiagnosis when evaluating central nervous system disordersand treatment with steroids should not be delayed if thediagnosis is considered
activityg GramGCS Glasgow Coma ScoreHE Hashimotorsquos encephalopathyHSV Herpes simplex virusIUml International units per millilitermg Milligrammgl Milligram per litermm MillimetermmHg Millimeters mercurymmoll Millimole per literMRI Magnetic resonant imagingPCR Polymerase chain reactionSREAT Steroid-Responsive Encephalopathy
Associated with AutoimmuneThyroiditisT4 ThyroxineTSH Thyroid stimulating hormoneUL Units per liter
Conflicts of Interest
The authors declare that there are no conflicts of interestregarding the publication of this article
Authorsrsquo Contributions
All the authors were involved in patient management andcare The article was written by Chiranthi Kongala LiyanageTilak Manthi Janake Munasinghe and Adsareswary Para-manantham have made contributions to the analysis andinterpretation of data and have been involved in revisingthe manuscript All authors have given final approval of theversion to be published
References
[1] J Y Chong L P Rowland and R D Utiger ldquoHashimotoencephalopathy syndrome ormythrdquo JAMANeurology vol 60no 2 pp 164ndash171 2003
[2] J Payer T Petrovic L Lisy and P Langer ldquoHashimotoencephalopathy a rare intricate syndromerdquo International Jour-nal of Endocrinology andMetabolism vol 10 no 2 pp 506ndash5142012
[3] F Ferracci G Bertiato and G Moretto ldquoHashimotorsquosencephalopathy epidemiologic data and pathogeneticconsiderationsrdquo Journal of the Neurological Sciences vol217 no 2 pp 165ndash168 2004
[4] F H Mahmud A N Lteif D L Renaud A M Reed and CK Brands ldquoSteroid-responsive encephalopathy associated withHashimotorsquos thyroiditis in an adolescent with chronic halluci-nations and depression case report and reviewrdquo Pediatrics vol112 no 3 pp 686ndash690 2003
[5] Y Tang Y Xing M T Lin J Zhang and J Jia ldquoHashimotorsquosencephalopathy cases Chinese experiencerdquo BMC Neurologyvol 12 article 60 2012
[6] PM S SharmaM Javali RMahale B KMadhusudhan A AMajeed and R Srinivasa ldquoHashimoto encephalopathy A studyof the clinical profile radiological and electrophysiologicalcorrelation in a Tertiary Care Center in South Indiardquo Journal ofNeurosciences in Rural Practice vol 6 no 3 pp 309ndash314 2015
[7] C Laurent J Capron B Quillerou et al ldquoSteroid-responsiveencephalopathy associated with autoimmune thyroiditis(SREAT) Characteristics treatment and outcome in 251 casesfrom the literaturerdquo Autoimmunity Reviews vol 15 no 12 pp1129ndash1133 2016
[8] L Brain E H Jellinek and K Ball ldquoHashimotorsquos disease andencephalopathyrdquoThe Lancet vol 2 no 7462 pp 512ndash514 1966
[9] J Wang J Zhang L Xu et al ldquoCognitive impairments inhashimotorsquos encephalopathy a case-control studyrdquo PLoS ONEvol 8 no 2 article e55758 2013
[10] M Al-Busaidi J Burad A Al-Belushi and A Gujjar ldquoSuperrefractory status epilepticus in hashimotorsquos encephalopathyrdquoOman Medical Journal vol 32 no 3 pp 247ndash250 2017
[11] I Correia I B Marques R Ferreira and L Sousa ldquoEnceph-alopathy associated with autoimmune thyroid disease a poten-tially reversible conditionrdquo Case Reports in Medicine vol 2016Article ID 9183979 6 pages 2016
[12] P Castillo B Woodruff R Caselli et al ldquoSteroid-responsiveencephalopathy associated with autoimmune thyroiditisrdquoJAMA Neurology vol 63 no 2 pp 197ndash202 2006
[13] L Lalanne M-E Meriot E Ruppert M-A ZimmermannJ-M Danion and P Vidailhet ldquoAttempted infanticide andsuicide inaugurating catatonia associated with Hashimotorsquosencephalopathy A case reportrdquo BMC Psychiatry vol 16 no 1article 13 2016
4 Case Reports in Neurological Medicine
[14] AAlazzeh S JaroudiMGooch andAN Peiris ldquoFocal neuro-logical presentation in Hashimotorsquos encephalopathy mimickinga vascular occlusion of the middle cerebral arteryrdquo BMJ CaseReports article 219933 2017
[15] KAnand J Garg RVerma andAChakraborty ldquoHashimoto1015840sencephalitis unusual cause of reversible dementiardquo Journal ofFamily Medicine and Primary Care vol 3 no 3 pp 284ndash2862014
[16] T Chang M T M Riffsy and P S Gunaratne ldquoHashimotoencephalopathy Clinical and MRI improvement followinghigh-dose corticosteroid therapyrdquo The Neurologist vol 16 no6 pp 394ndash396 2010
[17] E Bonmann M Prumbaum C Stippich P Ringleb and USliwka ldquoHashimoto encephalopathy rare cause of stroke inyoung patientrdquoTheNeurologist vol 15 no 6 pp 342ndash344 2009
[18] B R Graham N Shiff M Nour S Hasal R Huntsman andS Almubarak ldquoHashimoto encephalopathy presenting withstroke-like episodes in an adolescent female a case report andliterature reviewrdquo Pediatric Neurology vol 59 pp 62ndash70 2016
[19] A Shindo Y Ii R Sasaki Y Takahashi M Yoneda and SKuzuhara ldquoNon-herpetic acute limbic encephalitis-like mani-festation in a case of Hashimotorsquos encephalopathy with positiveautoantibodies against ionotropic glutamate receptor 1205762rdquo Jour-nal of Clinical Neurology vol 47 no 10 pp 629ndash634 2007
[20] M-J Lee H-S Lee J-S Hwang and D-E Jung ldquoA caseof Hashimotorsquos encephalopathy presenting with seizures andpsychosisrdquo Korean Journal of Pediatrics vol 55 no 3 pp 111ndash113 2012
[21] T Lu Z Zhou A Wu B Qin and Z Lu ldquoFebrile Hashimotorsquosencephalopathy associated withHashitoxicosisrdquoActa Neurolog-ica Belgica vol 115 no 4 pp 811ndash813 2015
[22] R T R De Aquino and E G Mutarelli ldquoHashimotorsquos enceph-alopathyrdquo Arquivos de Neuro-Psiquiatria vol 67 no 3 A pp724-725 2009
[23] R Mocellin M Walterfang and D Velakoulis ldquoHashimotorsquosencephalopathy epidemiology pathogenesis and manage-mentrdquo CNS Drugs vol 21 no 10 pp 799ndash811 2007
[24] F Ferracci GMoretto RM Candeago et al ldquoAntithyroid anti-bodies in the CSF their role in the pathogenesis of Hashimotorsquosencephalopathyrdquo Neurology vol 60 no 4 pp 712ndash714 2003
[25] I Ilias V Karagiorga G Paraskevas et al ldquoThyroid autoanti-bodies in the cerebrospinal fluid of subjects with and withoutthyroid disease Implications for Hashimotorsquos encephalopathyrdquoJournal ofThyroid Research vol 2015 Article ID 819072 4 pages2015
[14] AAlazzeh S JaroudiMGooch andAN Peiris ldquoFocal neuro-logical presentation in Hashimotorsquos encephalopathy mimickinga vascular occlusion of the middle cerebral arteryrdquo BMJ CaseReports article 219933 2017
[15] KAnand J Garg RVerma andAChakraborty ldquoHashimoto1015840sencephalitis unusual cause of reversible dementiardquo Journal ofFamily Medicine and Primary Care vol 3 no 3 pp 284ndash2862014
[16] T Chang M T M Riffsy and P S Gunaratne ldquoHashimotoencephalopathy Clinical and MRI improvement followinghigh-dose corticosteroid therapyrdquo The Neurologist vol 16 no6 pp 394ndash396 2010
[17] E Bonmann M Prumbaum C Stippich P Ringleb and USliwka ldquoHashimoto encephalopathy rare cause of stroke inyoung patientrdquoTheNeurologist vol 15 no 6 pp 342ndash344 2009
[18] B R Graham N Shiff M Nour S Hasal R Huntsman andS Almubarak ldquoHashimoto encephalopathy presenting withstroke-like episodes in an adolescent female a case report andliterature reviewrdquo Pediatric Neurology vol 59 pp 62ndash70 2016
[19] A Shindo Y Ii R Sasaki Y Takahashi M Yoneda and SKuzuhara ldquoNon-herpetic acute limbic encephalitis-like mani-festation in a case of Hashimotorsquos encephalopathy with positiveautoantibodies against ionotropic glutamate receptor 1205762rdquo Jour-nal of Clinical Neurology vol 47 no 10 pp 629ndash634 2007
[20] M-J Lee H-S Lee J-S Hwang and D-E Jung ldquoA caseof Hashimotorsquos encephalopathy presenting with seizures andpsychosisrdquo Korean Journal of Pediatrics vol 55 no 3 pp 111ndash113 2012
[21] T Lu Z Zhou A Wu B Qin and Z Lu ldquoFebrile Hashimotorsquosencephalopathy associated withHashitoxicosisrdquoActa Neurolog-ica Belgica vol 115 no 4 pp 811ndash813 2015
[22] R T R De Aquino and E G Mutarelli ldquoHashimotorsquos enceph-alopathyrdquo Arquivos de Neuro-Psiquiatria vol 67 no 3 A pp724-725 2009
[23] R Mocellin M Walterfang and D Velakoulis ldquoHashimotorsquosencephalopathy epidemiology pathogenesis and manage-mentrdquo CNS Drugs vol 21 no 10 pp 799ndash811 2007
[24] F Ferracci GMoretto RM Candeago et al ldquoAntithyroid anti-bodies in the CSF their role in the pathogenesis of Hashimotorsquosencephalopathyrdquo Neurology vol 60 no 4 pp 712ndash714 2003
[25] I Ilias V Karagiorga G Paraskevas et al ldquoThyroid autoanti-bodies in the cerebrospinal fluid of subjects with and withoutthyroid disease Implications for Hashimotorsquos encephalopathyrdquoJournal ofThyroid Research vol 2015 Article ID 819072 4 pages2015
