Endocrine Abstracts

32 year old female with no prior past medical problems presented to hospital with a two week history of rapid onset delusional psychosis with religious themes, paranoid ideas and rapidly developing into catatonia. There was no previous history of psychiatric disorders. On physical examination the Glasgow Coma Score (GCS) was 15 and she was responding to visual hallucinations; speaking to imaginary person and reported seeing objects. She was afebrile and bedside observations were within normal range. Systemic examination was grossly normal except bilateral brisk reflexes were elicited. Soon after admission her GCS started to deteriorate and she became catatonic, mumbling words and maintaining spontaneous eye movements (V2 E4 M3). Initial investigations including full blood count, renal function, liver function, CRP and ESR were within normal range. Her thyroid function results demonstrated an elevated TSH 46mU/l (0.27-4.2), Free T4 10 pmol/l (12-22), Free T3 4.0 pmol/l (3.1-6.8), antiTPO antibodies present in elevated concentrations >999.9 IU/l (0-5.5). The remainder of the pituitary profile was within normal range. MRI of brain, CT CAP and ultrasound of abdomen were reported as normal. Lumbar puncture had normal cell count and protein and glucose. NMDA antibodies were negative. Subsequent focused neurological assessment found sustained ankle clonus and bilaterally extensor planters. Diagnosis of Hashimoto’s Encephalopathy was made and she was commenced on methylprednisolone, thyroxine and lorazepam after consultation with neurology and psychiatry teams. Her symptoms improved dramatically within 2 weeks of treatment and was able to be discharged home with outpatient follow up. Hashimoto’s Encephalopathy is a rare syndrome associated with autoimmune thyroiditis, first reported in 1966 and remains an important differential in patients with psychosis and needs prompt recognition for appropriate treatment to be commenced.