On the edge of your SREAT: A Case Report and Literature Review on Management Strategies for Hashimoto's Encephalopathy.

Abstract:

Background:

Hashimoto encephalopathy (HE) is a rare clinical condition, and it can present with various motor and behavioral symptoms (1). Diagnostic criteria are well-documented and include encephalopathy in setting of evidence of autoimmune thyroid disease (2). Herein, we present a case of HE with parkinsonism and psychosis, that was not responsive to immune-modulating therapies but did improve with thyroidectomy and review literature on treating HE.


Method:

We conducted a systematic literature search on Web of Science and PubMed using the keywords "Hashimoto’s Encephal*” OR “SREAT” AND "thyroidectomy”. Specifically, we focused on case reports that detailed cases of Hashimoto's Encephalopathy treated with thyroidectomy. Our search yielded 4 publications, showcasing 7 cases of HE with varying responses to treatments.


Results:

A 68-year-old female patient with a past psychiatric history of anxiety disorder was admitted to the inpatient psychiatric hospital subacute delusions, and auditory and visual hallucinations. Prior to presentation, she refused surgical management of thyroid and ovarian masses found on imaging due to delusional beliefs. She was found to have parkinsonism as well during clinical evaluation. Quetiapine was initiated though not titrated to therapeutic dose as she was transferred to medical hospital for further workup. Testing including CBC, CMP, TSH, T4, T3, UDS, EEG, and MRI. were normal. Lumbar puncture revealed mild protein elevation with a level of 92 (reference: 15-45). Anti-NMDA and the paraneoplastic antibody panel in the blood and CSF were negative. Anti-TPO was 40 (reference: < 10) and anti-TG was 16 (reference: < 1). Subsequently, the patient was started on high-dose prednisone and IVIG were trialed with no significant improvement. Eventually, the patient had surgical removal of ovarian and later thyroid masses. Despite benign findings on thyroid specimen, she immediately demonstrated improved affect and insight into psychotic symptoms. At outpatient follow-up, psychotic symptoms and parkinsonism were resolved.


Discussion:

Herein, we present a case of late-onset psychosis in the setting of autoimmune thyroiditis. This case illustrates a rare scenario where traditional treatments, including steroids and IVIG, proved ineffective, yet surgical intervention was successful. Despite meeting the criteria for Hashimoto's Encephalopathy and experiencing complete symptom resolution following thyroidectomy, the pathology report did not indicate Hashimoto Thyroiditis, suggesting that the etiology of the encephalopathy may involve mechanisms beyond those typically associated with Hashimoto's thyroiditis.



Conclusion:

Our literature review identified seven cases of HE that achieved symptom relief post-thyroidectomy. Notably, one case report SREAT after partial thyroidectomy (3). This highlights the potential efficacy of thyroidectomy in refractory HE cases. Additionally, our findings suggest the existence of alternative pathological mechanisms underlying steroid-unresponsive encephalopathy.


References:

1) Chaudhuri, J., Mukherjee, A., & Chakravarty, A. (2023). Hashimoto's Encephalopathy: Case Series and Literature Review. Current neurology and neuroscience reports, 23(4), 167–175.

2) Graus F, Titulaer MJ, Balu R, Benseler S, Bien CG, Cellucci TJ. A clinical approach to diagnosis of autoimmune encephalitis. Lancet Neurol. 2016;15:391–404.

3) Adithya-Sateesh, B., Gousy, N., Gogna, G., Ayele, G. M., Michael, M., & Munir, K. M. (2023). Encephalopathy of Autoimmune Origin: Steroid-Responsive Encephalopathy With Associated Thyroiditis. AACE clinical case reports, 9(6), 205–208.1

Presentation Eligibility: Not previously published or presented.

Diversity, Equity, and Inclusion: This abstract contributes to diversity, equity, and inclusion by shedding light on the intersection of autoimmune thyroiditis and neuropsychiatric symptoms, which can affect individuals from different backgrounds including geriatric population. By highlighting the successful treatment of Hashimoto encephalitis with thyroidectomy, it emphasizes the importance of considering alternative interventions for patients who may not respond to traditional therapies.