Endocrine Abstracts

Case History: We describe a case of a 30-year-old female who presented at 8 weeks postpartum with history of altered behaviour, clouding of consciousness and status epilepticus. She had been diagnosed with autoimmune graves thyroid disease and was commenced on carbimazole prior to this episode. She was treated as meningoencephalitis. Also, consideration was given for possibility of thyroid storm and post-partum eclampsia. She was intubated and ventilated, treated with IV acyclovir, IV ceftriaxone, IV Keppra and IV magnesium. Lugol’s iodine and propylthiouracil was also started for thyroid storm.

Treatment: She was extubated after 3 days, but she continued to be confused and noncommunicative. A diagnosis of autoimmune thyroid disease encephalopathy (EAATD) was made, and high dose steroid therapy was initiated. She was also given IV Pabrinex as high metabolic state was considered. Over the next few days, she improved steadily nevertheless continued to have poor short-term memory of events like childbirth. She then recovered fully around 6 weeks. The steroid was weaned and stopped over the period of next six weeks. She was discharged on block and replace regime and Keppra awaiting a thyroidectomy surgery. Five months later she presented again with seizures after consuming alcohol which was treated similarly.

Investigations: At initial presentation, routine blood tests showed normal white cell count, C reactive protein was 25 mg/l, Blood glucose was 6.7 mmol/l, Thyroid stimulating hormone <0.05 mU/l, Free thyroxine-84.2 pmol/l, Free triiodothyronine-15.2 pmol/l, Thyroid peroxidase 344 IU/mL. Anti-Thyroid receptor antibodies were negative. CT Head, MRI Head, Pituitary and MR Venogram was normal, Cerebrospinal fluid looked clear, raised protein 0.74, CSF glucose was 3.7, WCC were zero, microscopy and culture showed no organism, negative for viral screen on polymerase chain reaction.

Conclusion: Encephalopathy associated with autoimmune thyroid disease(EAATD) has been described in the literature with following features: – Neurological/psychiatric symptoms, high levels of anti-thyroid antibodies, raised cerebrospinal fluid protein levels, non-specific diffuse electroencephalogram changes and responsiveness to the corticosteroid treatment (1). Clinical presentation entails relapsing and remitting course. (1) Makoto et al found out that the serum antibodies against the NH2-terminal of alpha-enolase (NAE) are highly specific diagnostic biomarkers for EAATD. Immunoglibulins and plasma exchange were efficacious other treatments. This case highlights the importance of considering thyroid encephalopathy in all patients with signs of encephalopathy of unknown origin and autoimmune thyroid disease. The need for prompt initiation of steroids. 1. Tamagno et al, BMC neurology 2010,10:27, 2. Makoto Yoneda, Brain Nerve 2013 Apr;65(4):365-76.