J Korean Acad Child Adolesc Psychiatry.  2019 Jan;30(1):42-44. 10.5765/jkacap.180022.

Psychotic Symptoms of Hashimoto's Encephalopathy: A Diagnostic Challenge

• Savarimuthu MK
• Tsheringla S
• Mammen P

• KMID: 2438613
• DOI: http://doi.org/10.5765/jkacap.180022

Abstract

Hashimoto's encephalopathy (HE) is a rare and underdiagnosed neuropsychiatric illness. We present the case of a 17-year-old girl who was admitted to a tertiary-care psychiatric center with acute onset psychosis and fever. Her psychotic symptoms were characterized by persecutory and referential delusions, as well as tactile and visual hallucinations. Her acute behavioral disturbance warranted admission and treatment in a psychiatric setting (risperidone tablets, 3 mg/day). She had experienced an episode of fever with a unilateral visual acuity defect approximately 3 years before admission, which was resolved with treatment. Focused clinical examination revealed an enlarged thyroid, and baseline blood investigations, including thyroid function test results were normal. Abnormal laboratory investigations revealed elevated anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-TG) levels (anti-TPO of 480 IU/mL; anti-TG of 287 IU/mL). Results of other investigations for infection, including cerebrospinal fluid examination, electroencephalography, and brain magnetic resonance imaging were normal. She was diagnosed with HE and was treated with intravenous corticosteroids (methylprednisolone up to 1 g/day; tapered and discontinued after a month). The patient achieved complete remission of psychotic symptoms and normalization of the anti-thyroid antibody titers. Currently, at the seventh month of follow-up, the patient is doing well. This case highlights the fact that in the absence of well-defined clinical diagnostic criteria, a high index of suspicion is required for early diagnosis of HE. Psychiatrists need to explore for organic etiologies when dealing with acute psychiatric symptoms in a younger age group.

Keyword

Hashimoto's encephalopathy; Steroid responsive encephalopathy associated with autoimmune thyroiditis; Risperidone; Steroid; Methylprednisolone; Psychosis; Anti-thyroid antibodies

MeSH Terms

Adolescent
Adrenal Cortex Hormones
Brain
Brain Diseases*
Cerebrospinal Fluid
Delusions
Early Diagnosis
Electroencephalography
Female
Fever
Follow-Up Studies
Hallucinations
Humans
Magnetic Resonance Imaging
Methylprednisolone
Peroxidase
Psychiatry
Psychotic Disorders
Risperidone
Tablets
Thyroid Function Tests
Thyroid Gland
Visual Acuity
Adrenal Cortex Hormones
Methylprednisolone
Peroxidase
Risperidone
Tablets