Endocrine Abstracts

Introduction: In rare but severe cases, Hashimoto’s thyroiditis can present with neurological manifestations including stroke-like episodes, cognitive decline, neuropsychiatric symptoms, and coma. This is referred to as Hashimoto’s encephalopathy which is characterized by high titers of antithyroid peroxidase antibodies and is responsive to steroids. Herein, we present a case of a patient with acute onset aphasia, altered mental status with progression to respiratory distress and intubation who was promptly identified to have Hashimoto’s encephalopathy and treated with steroids.

Case description: A 59-year-old female with a history of ESRD presented with acute onset aphasia, confusion and involuntary body shaking. Due to lab abnormalities meningoencephalopathy initially considered however patient was unresponsive to antimicrobial therapy. Further lab studies, LPx2, MRIx2 did not support infectious etiology. Patient became increasingly agitated and hypertensive requiring precedex, nicardipine drip and transfer to ICU where she was subsequently intubated for airway protection. Labs noted elevated TSH at 10.5 with normal free T4 at 1.2, and elevated TPO-Ab at 2100. In absence of alternate etiology Hashimoto’s encephalopathy was considered and she was started on three-day course of 1g Solumedrol. She was successfully extubated on the third day and her mental status returned to baseline with resolution of all symptoms. Patient was eventually discharged home on steroid taper.

Discussion: Hashimoto’s encephalopathy remains a diagnosis of exclusion. Although a strong association with autoimmune thyroid disease exists, the etiology of Hashimoto’s encephalopathy still remains unclear. More than 60% of the cases in literature are noted to either clinically euthyroid or subclinically hypothyroid. Taking this into account, the value of high antithyroid antibodies may less likely be pathogenic and may be better utilized as a marker of treatment response instead. Further research regarding this disease process is therefore required in pursuit of clear guidelines for diagnosis and treatment.