{"id":63527,"date":"2023-07-18T12:22:59","date_gmt":"2023-07-18T11:22:59","guid":{"rendered":"https:\/\/touchneurology.com\/?p=63527"},"modified":"2023-11-30T16:08:52","modified_gmt":"2023-11-30T16:08:52","slug":"a-rare-presentation-of-steroid-responsive-encephalopathy-associated-with-autoimmune-thyroiditis-with-neuropsychiatric-symptoms-a-case-report","status":"publish","type":"post","link":"https:\/\/touchneurology.com\/neuroimmunology\/journal-articles\/a-rare-presentation-of-steroid-responsive-encephalopathy-associated-with-autoimmune-thyroiditis-with-neuropsychiatric-symptoms-a-case-report\/","title":{"rendered":"A Rare Presentation of Steroid-responsive Encephalopathy Associated with Autoimmune Thyroiditis with Neuropsychiatric Symptoms: A Case Report"},"content":{"rendered":"

Case study<\/h1>\n

Patient information<\/span><\/h2>\n

A 42-year-old woman presented in the emergency department with acute onset whole-body myoclonic jerks for 1 day. On enquiry, the patient\u2019s parents advised that she had a history of depression over the past 15 years. Intermittently, family members had also noticed aggressive and abusive behaviour. She had been evaluated and diagnosed with hypothyroidism. She was on irregular medication for depression and hypothyroidism.<\/p>\n

Informed consent<\/h2>\n

Written consent for the publication of this case report was obtained from the parents of the patient.<\/p>\n

Clinical findings<\/span><\/h2>\n

The patient was conscious, oriented and alert. At rest, multifocal, mild-to-moderate myoclonus was detected in all four extremities; this was dramatically worsened by muscular activation. Reflex sensitivity was present. The rest of the neurologic evaluation was uneventful. She had a score of 21 on the\u00a0Hamilton Depression Rating Scale (HAM-D)<\/span>.<\/p>\n

Diagnostic assessment<\/span><\/h2>\n

The patient\u2019s laboratory evaluation showed elevated antithyroid autoantibodies. Antithyroglobulin (anti-TG) antibody level was >2000 IU\/mL and the antithyroid peroxidase autoantibody (anti-TPOAb) level was >2,000 IU\/mL. Thyroid function test showed a thyroid stimulating hormone (TSH) value of 5.65 mIU\/mL; a free triiodothyronine value of 3.36 pg\/mL and a free thyroxine value of 1.02 ng\/dL. The patient had a vitamin B12 level of 6,764 pg\/mL, a folate level of 8 ng\/mL and a vitamin D3 level of 121 pmol\/L. Her cholesterol level was 244 mg\/dL, with a\u00a0low-density lipoprotein<\/span>\u00a0level of 156 mg\/dL and normal triglyceride level. The\u00a0antinuclear antibody and extractable nuclear antigen<\/span>\u00a0profiles were negative. Cytoplasmic antineutrophil cytoplasmic antibodies and perinuclear antineutrophil cytoplasmic antibodies were negative. The serum test for autoimmune encephalitis panel was also negative. The neck ultrasonography showed a diffusely enlarged thyroid gland with evidence of calcification, haemorrhage and necrosis. Brain magnetic resonance imaging (MRI) was normal. The interictal\u00a0electroencephalogram<\/span>\u00a0<\/span>(EEG) findings were normal. The patient was diagnosed with SREAT after meeting the diagnostic criteria points 1\u20136 of the proposed steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) diagnostic criteria:1<\/sup><\/span><\/p>\n

    \n
  1. \n

    Encephalopathy with seizures, myoclonus, hallucinations or stroke-like episodes.<\/span><\/p>\n<\/li>\n

  2. \n

    Subclinical or mild overt thyroid disease (usually hypothyroidism).<\/span><\/p>\n<\/li>\n

  3. \n

    Brain MRI normal or with non-specific abnormalities.<\/span><\/p>\n<\/li>\n

  4. \n

    Presence of serum thyroid (thyroid peroxidase, thyroglobulin) antibodies.<\/span><\/p>\n<\/li>\n

  5. \n

    Absence of well-characterized neuronal antibodies in serum and cerebrospinal fluid (CSF).<\/span><\/p>\n<\/li>\n

  6. \n

    Reasonable exclusion of alternative causes.<\/span><\/p>\n<\/li>\n<\/ol>\n

    Therapeutic intervention<\/span><\/h2>\n

    The patient was treated with a high dose of methylprednisolone (1 gm\/day) for the first 5 days, followed by a dose of oral prednisolone of 60 mg.<\/p>\n

    Follow-ups and outcomes<\/span><\/h2>\n

    The patient’s myoclonic jerks disappeared after she started taking pulse dose of methylprednisolone, and her depression symptoms also improved. A psychiatric evaluation was obtained for depression, and sertraline 100 mg tablet twice daily and risperidone 1 mg twice daily were prescribed. Her HAM-D rating score at the time of discharge was 12.<\/p>\n

    Discussion<\/span><\/h1>\n

    SREAT (also called Hashimoto\u2019s encephalopathy [HE] or Hashimoto\u2019s thyroiditis), which was first described in 1966, is still a contentious and poorly understood condition.2<\/sup><\/span>\u00a0SREAT is thought to be a neuroimmunological illness rather than a direct effect of thyroid dysfunction on the central nervous system.<\/p>\n

    The exact pathophysiology of SREAT remains unclear, and several pathophysiologies have been hypothesized.3<\/sup><\/span>\u00a0SREAT may represent an immune complex disease or a primary demyelinating process, such as acute disseminated encephalomyelitis.4\u20136<\/sup><\/span>\u00a0It may result from a direct antibody neuronal injury,7<\/sup><\/span>\u00a0or vasculitis from endothelial inflammation or immune complex deposition.8<\/sup><\/span><\/p>\n

    In line with most autoimmune disorders being more common in women, SREAT is also more common in women.9<\/sup><\/span><\/p>\n

    Acute-to-subacute onset of altered consciousness is the most common clinical symptom of SREAT. Focal or generalized tonic-clonic seizures are a common SREAT manifestation, affecting around one-half to two-thirds of patients.10,11<\/sup><\/span>\u00a0Status epilepticus has been reported in 25% of these patients. Approximately 38% of patients have focal or multifocal myoclonus. Among patients with SREAT, 25% can manifest multiple, recurrent, stroke-like focal neurological deficits.12<\/sup><\/span>\u00a0SREAT can also have a limbic encephalitis-like presentation, with subacute onset memory impairments, decreased level of consciousness, seizures and behavioural abnormalities.13<\/sup><\/span><\/p>\n

    SREAT can also have a chronic course, which is marked by slowly growing cognitive impairments, somnolence and confusion.14<\/sup><\/span>\u00a0Psychosis, specifically visual hallucinations but also paranoid delusions, has been recorded in 25\u201336% of patients with SREAT. Among individuals with SREAT, 10\u201325% may present with isolated psychiatric symptoms such as depression, delusion or hallucination.10<\/sup><\/span><\/p>\n

    Laboratory features<\/h2>\n

    An essential criterion for SREAT is an elevated serum level of anti-TPOAb and\/or anti-TG. A systematic review reported that the median anti-TPOAb level at diagnosis is 900 IU\/mL.11<\/sup><\/span>\u00a0In a review of 105 patients with HE, anti-TPOab were elevated in 100% of patients, and TgAb\/anti-TG antibodies were elevated in 48% of them.15<\/sup><\/span>\u00a0However, antibody titres do not correspond with disease activity. Furthermore, the presence of thyroid antibodies is not specific, as approximately 10% of the general population has raised serum anti-TPOab.16<\/sup><\/span><\/p>\n

    The role of CSF analysis in SREAT is not entirely established. However, it should be conducted to rule out other common differential diagnoses, as mentioned below. An abnormal CSF analysis with an elevated protein concentration and normal glucose level can be seen in around 80% of SREAT cases. A mild lymphocytic pleocytosis can be seen in 10\u201325% of patients.5,7<\/sup><\/span>\u00a0Antithyroid antibodies are infrequently measured in CSF. Additionally, the specificity and sensitivity of antithyroid antibodies in the CSF are unclear.7<\/sup><\/span>\u00a0Other rare findings that are reported are oligoclonal bands and elevated 14-3-3 protein level.17<\/sup><\/span><\/p>\n

    Thyroid disease in SREAT ranges from overt hypothyroidism to overt hyperthyroidism. According to a systematic review, most patients remain euthyroid. Subclinical hypothyroidism is the most common abnormality (23\u201335%), followed by overt hypothyroidism (17\u201325%). Hyperthyroidism is very rare, and is found in approximately 7% of patients.7,8,18<\/sup><\/span><\/p>\n

    Non-specific slowing of background activity in the EEG can be seen in 90\u201398% of patients. Other less common EEG findings that have been reported are focal spikes, sharp waves, triphasic waves and frontal intermittent rhythmic delta activity.18,19<\/sup><\/span>\u00a0Brain MRI results are usually normal in individuals with SREAT; however, approximately half of patients may demonstrate cerebral atrophy or non-specific T2 signal abnormalities in the subcortical white matter.20<\/sup><\/span>\u00a0Single-photon emission computed tomography (SPECT) may show focal, multifocal or global hypoperfusion.21<\/sup><\/span>\u00a0<\/sup><\/span>Acute phase reactants such as C-reactive protein and the erythrocyte sedimentation rate can also be raised in some cases. A modest increase of liver enzymes can occur in 12\u201320% of patients.20<\/sup><\/span><\/sup><\/span><\/p>\n

    Furthermore, newer techniques, such as event-related potentials and magnetic resonance spectroscopy, can be used to recognize and monitor cognitive functions in patients with SREAT. The N-acetylaspartate\/creatine ratio exhibited significant negative correlations with all N200 latencies, whereas the\u00a0myo-inositol\/total creatine<\/span>\u00a0ratio exhibited significant positive correlations with P300 latencies, implying that decreased values of the N200 and P300 latencies are associated with metabolic changes in the posterior cingulate cortex.22<\/sup><\/span><\/p>\n

    Changes in the bioelectrical activity of the brain during the course of SREAT in people with euthyroid sick syndrome may indicate an autoimmune process. In a study of 100 patients with SREAT, 34% had aberrant visual evoked potentials and brainstem auditory evoked potentials.23<\/sup><\/span>\u00a0There was a link between TSH levels and wave brainstem auditory evoked potentials III-V interpeak latency. In recent years, antibodies against \u03b1-enolase have been discovered in the serum and cerebral fluid of SREAT patients as a potential biomarker. The presence of \u03b1-enolase in individuals with HE was found in 68% of patients compared with 12% of patients with autoimmune thyroiditis without encephalopathy.24<\/sup><\/span>\u00a0These antibodies, which are not specific, have been found in patients with Creutzfeldt-Jakob disease and limbic encephalitis.24<\/sup><\/span>\u00a0Differential diagnoses of SREAT include acute disseminated encephalomyelitis, toxic metabolic encephalopathies, meningoencephalitis, psychiatric disease (depression, anxiety and psychosis), carcinomatous meningitis,\u00a0paraneoplastic or autoimmune encephalitis, degenerative dementia (Alzheimer’s disease, dementia with Lewy bodies, frontotemporal dementia), stroke or transient ischemic attack, basilar or hemiplegic migraines, and central nervous system vasculitis<\/span>.24<\/sup><\/span><\/p>\n

    Diagnosis<\/span><\/h1>\n

    Elevated levels of anti-TPOAb or TgAb\/anti-TG antibodies with a compatible clinical presentation and a response to glucocorticoids generally define the diagnosis of SREAT. Thyroid hormone levels are variable, with euthyroidism being the most common.<\/p>\n

    Proposed diagnostic criteria<\/span><\/h1>\n

    Diagnosis can be made when all six of the following criteria have been met:1<\/sup><\/span><\/p>\n

      \n
    1. \n

      Encephalopathy with seizures, myoclonus, hallucinations or stroke-like episodes<\/p>\n<\/li>\n

    2. \n

      Subclinical or mild overt thyroid disease (usually hypothyroidism)<\/p>\n<\/li>\n

    3. \n

      Normal brain MRI or with non-specific abnormalities<\/p>\n<\/li>\n

    4. \n

      Presence of serum thyroid (thyroid peroxidase, thyroglobulin) antibodies.<\/p>\n<\/li>\n

    5. \n

      Absence of well-characterized neuronal antibodies in serum and CSF.<\/p>\n<\/li>\n

    6. \n

      Reasonable exclusion of alternative causes.<\/p>\n<\/li>\n<\/ol>\n

      Treatment<\/span><\/h1>\n

      Glucocorticoids remain the standard of treatment for SREAT. Pulse methylprednisolone is usually administered, followed by oral steroids.9,11<\/sup><\/span>\u00a0Symptoms typically improve over a few months in most patients. However, recovery may be incomplete. According to a series including 24 patients, only 32% of them had a complete response to steroids.11<\/sup><\/span><\/p>\n

      There is no clear association between serum antibody titres and response to treatment. In addition, antibody levels may or may not decrease following treatment.25<\/sup><\/span><\/p>\n

      The duration of treatment and rate of taper are generally titrated according to the clinical response. Treatment with steroid-sparing agents, including azathioprine, mycophenolate mofetil, cyclophosphamide and rituximab, should be considered in patients not responding to steroids.20,26\u201330<\/sup><\/span>\u00a0The roles of intravenous immune globulin and plasmapheresis have been described in individual cases.28\u201330<\/sup><\/span>\u00a0Treatment of a dysthyroid state also goes in parallel, and antiseizure medications may be necessary as a temporary measure.<\/p>\n

      Prognosis<\/span><\/h1>\n

      Most patients remain in remission after discontinuation of steroids over several years of follow-up. A complete or partial neurologic response has been reported in 93% of cases three months after the initial diagnosis. Relapses are seen among 16% of patients over a median follow-up of 1 year.11,30<\/sup><\/span>\u00a0However, some patients may need long-term immunosuppression.30<\/sup><\/span><\/p>\n

      Patient perspective<\/span><\/h2>\n

      The patient said: \u201cFor a long period, I struggled with depression and hypothyroidism. I was in with a seizure and was in a coma. Thanks to the treatment, I was able to improve my symptoms and stop having seizures.\u201d<\/p>\n

      Conclusion<\/h1>\n

      SREAT\u00a0<\/span><\/span><\/span>is a treatable disorder\u00a0<\/span><\/span><\/span><\/span><\/span><\/span><\/span><\/span><\/span><\/span><\/span>that\u00a0<\/span><\/span>can\u00a0<\/span><\/span><\/span>show\u00a0<\/span><\/span><\/span>with\u00a0<\/span><\/span><\/span>chronic\u00a0<\/span><\/span><\/span>neuropsychiatric\u00a0<\/span><\/span>symptoms\u00a0<\/span><\/span><\/span>such\u00a0<\/span><\/span>as\u00a0<\/span><\/span><\/span>seizures\u00a0<\/span><\/span><\/span>and\u00a0<\/span><\/span><\/span>myoclonus.\u00a0This\u00a0<\/span><\/span><\/span>case\u00a0<\/span><\/span>study\u00a0<\/span><\/span><\/span>emphasizes\u00a0<\/span><\/span>the\u00a0<\/span><\/span>necessity\u00a0<\/span><\/span><\/span>of\u00a0<\/span><\/span><\/span>screening\u00a0<\/span><\/span><\/span>people\u00a0<\/span><\/span>with\u00a0<\/span><\/span>depression\u00a0<\/span><\/span><\/span>and\u00a0<\/span><\/span><\/span>thyroid\u00a0<\/span><\/span>disorders\u00a0<\/span><\/span><\/span>for\u00a0<\/span><\/span><\/span>serum\u00a0<\/span><\/span><\/span>antithyroid\u00a0<\/span><\/span><\/span>antibody\u00a0<\/span><\/span>levels,\u00a0<\/span><\/span><\/span>which\u00a0<\/span><\/span><\/span>aid\u00a0<\/span><\/span><\/span>in\u00a0<\/span><\/span>the\u00a0<\/span><\/span><\/span>early\u00a0<\/span><\/span>detection\u00a0<\/span><\/span>and\u00a0<\/span><\/span>treatment\u00a0<\/span><\/span><\/span>of\u00a0<\/span><\/span><\/span>SREAT.\u00a0<\/span><\/span><\/span><\/span><\/span>In\u00a0<\/span><\/span>most\u00a0<\/span><\/span><\/span>cases,\u00a0<\/span><\/span><\/span>steroid\u00a0<\/span><\/span><\/span>therapy\u00a0<\/span><\/span>is\u00a0<\/span><\/span>beneficial.<\/span><\/span><\/span><\/span><\/span><\/span><\/span><\/span><\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

      Case study Patient information A 42-year-old woman presented in the emergency department with acute onset whole-body myoclonic jerks for 1 day. On enquiry, the patient\u2019s parents advised that she had a history of depression over the past 15 years. Intermittently, family members had also noticed aggressive and abusive behaviour. She had been evaluated and diagnosed […]<\/p>\n","protected":false},"author":142327,"featured_media":63587,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","rank_math_lock_modified_date":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-63527","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized","vocabulary_1-neuroimmunology","journal-touchreviews-neurology"],"acf":{"wpcf-article_introduction":"","wpcf-article_abstract":"

      \r\n

      Background<\/h2>\r\n

      Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) is an autoimmune disease that appears as a fulminant, subacute or chronic course of altered mental status, often accompanied by seizures and myoclonus. This case report demonstrates that SREAT can be present with solitary neuropsychiatric signs long before seizures and myoclonus.<\/span><\/p>\r\n\r\n

      <\/h2>\r\n

      Methods<\/h2>\r\n

      A 42-year-old female presented with abrupt-onset whole-body myoclonic jerks. She had been suffering from depression for 15 years before being diagnosed with hypothyroidism. She was conscious, oriented and alert. At rest, all four limbs had multifocal mild-to-moderate myoclonus, which was significantly aggravated by muscle activation; her Hamilton Depression Rating Scale score was 21.<\/span><\/p>\r\n\r\n

      Results<\/h2>\r\n

      Antithyroglobulin and antithyroid peroxidase autoantibodies were both above 2,000 IU\/mL. The thyroid-stimulating hormone level was 5.65\u00a0m<\/span><\/span>IU\/mL, free triiodothyronine level was 3.36 pg\/mL and free thyroxine level was 1.02 ng\/dL. Vasculitis profile and the serum test for autoimmune encephalitis panel were negative. Brain neuroimaging was normal. Pulse dose of methylprednisolone followed by oral steroids resulted in significant clinical improvement.<\/b><\/span><\/p>\r\n\r\n

      Conclusion<\/h2>\r\n

      SREAT can present with chronic neuropsychiatric symptoms with abrupt exacerbation of seizures and myoclonus. This case study emphasizes the importance of screening individuals with depression and thyroid problems for serum antithyroid antibody levels. In most cases, steroid treatment yields positive results.<\/span><\/p>\r\n\r\n<\/div>\r\n

      \r\n

      <\/h3>\r\n<\/div>","wpcf-article_keywords":"Autoimmune encephalopathy,\u00a0autoimmunity,\u00a0Hashimoto encephalopathy,\u00a0hypothyroidism,\u00a0neuropsychiatry,\u00a0steroid-responsive encephalopathy associated with autoimmune thyroiditis","wpcf-article_citation_override":"touchREVIEWS in Neurology.<\/i> 2023;19(2):16-18","wpcf-compliance-with-ethics":"
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      This study was performed in accordance with the Helsinki Declaration of 1964, and its later amendments. Ethics approval was not required as case studies are not subject to the authors' institutional review board approval, Max Health Care Institutional Scientific Committee and Institutional Ethics Committees. Written consent for the publication of this case report was obtained from the parents of the patient.<\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>","wpcf-article_disclosure":"

      \r\n
      \r\n
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      Prashant Bhatele and Manoj Khanal have no financial or non-financial relationships or activities to declare in relation to this article.<\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n

      <\/div>","wpcf-review_process":"
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      Double-blind peer review.<\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>","wpcf-authorship":"The named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published.","wpcf-article_correspondence":"

      Manoj<\/span>\u00a0Khanal<\/span><\/span>,\u00a0Department of Neurology<\/span>,\u00a0Room 1034, Max Institute of Health Care<\/span>,\u00a0Shalimar Bagh, New Delhi<\/span>,\u00a0India<\/span><\/span>; E: 03236316p@gmail.com<\/span><\/p>\r\n\r\n

      \r\n
      <\/div>\r\n<\/div>","wpcf-article_support":"No funding was received in the publication of this article.","wpcf-open_access":"This article is freely accessible at touchNEUROLOGY.com. \u00a9 Touch Medical Media 2023","wpcf-article_pdf":"https:\/\/touchneurology.com\/wp-content\/uploads\/sites\/3\/2023\/07\/touchNEURO_19.2_pp16-18.pdf","wpcf-article_pdf-gated":false,"wpcf-article_doi":"http:\/\/doi.org\/10.17925\/USN.2023.19.2.4","wpcf-old_nid":"","wpcf-article_image":"","wpcf-editor_choice":false,"wpcf-old_author_ids":"","wpcf-article_references":"

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      8.<\/span>\u00a0Ferracci<\/span>\u00a0F<\/span><\/span>,\u00a0Carnevale<\/span>\u00a0A<\/span><\/span>.\u00a0The neurological disorder associated with thyroid autoimmunity<\/span>.\u00a0J Neurol<\/em><\/span>.\u00a02006<\/span>;253<\/span>:975<\/span>\u201384<\/span>.\u00a0DOI<\/span>:\u00a010.1007\/s00415-006-0170-7<\/span>.<\/p>\r\n

      9.<\/span>\u00a0Kothbauer-Margreiter<\/span>\u00a0I<\/span><\/span>,\u00a0Sturzenegger<\/span>\u00a0M<\/span><\/span>,\u00a0Komor<\/span>\u00a0J<\/span><\/span>,\u00a0et al<\/span>.\u00a0Encephalopathy associated with Hashimoto thyroiditis: Diagnosis and treatment<\/span>.\u00a0J Neurol<\/em><\/span>.\u00a01996<\/span>;243<\/span>:585<\/span>\u201393<\/span>.\u00a0DOI<\/span>:\u00a010.1007\/BF00900946<\/span>.<\/p>\r\n

      10.<\/span>\u00a0McKeon<\/span>\u00a0A<\/span><\/span>,\u00a0McNamara<\/span>\u00a0B<\/span><\/span>,\u00a0Sweeney<\/span>\u00a0B<\/span><\/span>.\u00a0Hashimoto\u2019s encephalopathy presenting with psychosis and generalized absence status<\/span>.\u00a0J Neurol<\/em><\/span>.\u00a02004<\/span>;251<\/span>:1025<\/span>\u20137<\/span>.\u00a0DOI<\/span>:\u00a010.1007\/s00415-004-0490-4<\/span>.<\/p>\r\n

      11.<\/span>\u00a0Laurent<\/span>\u00a0C<\/span><\/span>,\u00a0Capron<\/span>\u00a0J<\/span><\/span>,\u00a0Quillerou<\/span>\u00a0B<\/span><\/span>,\u00a0et al<\/span>.\u00a0Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT): Characteristics, treatment and outcome in 251 cases from the literature<\/span>.\u00a0Autoimmun Rev<\/em><\/span>.\u00a02016<\/span>;15<\/span>:1129<\/span>\u201333<\/span>.\u00a0DOI<\/span>:\u00a010.1016\/j.autrev.2016.09.008<\/span>.<\/p>\r\n

      12.<\/span>\u00a0Mattozzi<\/span>\u00a0S<\/span><\/span>,\u00a0Sabater<\/span>\u00a0L<\/span><\/span>,\u00a0Escudero<\/span>\u00a0D<\/span><\/span>,\u00a0et al<\/span>.\u00a0Hashimoto encephalopathy in the 21st century<\/span>.\u00a0Neurology<\/em><\/span>.\u00a02020<\/span>;94<\/span>:e217<\/span>\u201324<\/span>.\u00a0DOI<\/span>:\u00a010.1212\/WNL.0000000000008785<\/span>.<\/p>\r\n

      13.<\/span>\u00a0Nagano<\/span>\u00a0M<\/span><\/span>,\u00a0Kobayashi<\/span>\u00a0K<\/span><\/span>,\u00a0Yamada-Otani<\/span>\u00a0M<\/span><\/span>,\u00a0et al<\/span>.\u00a0Hashimoto's encephalopathy presenting with smoldering limbic encephalitis<\/span>.\u00a0Intern Med<\/em><\/span>.\u00a02019<\/span>;58<\/span>:1167<\/span>\u201372<\/span>.\u00a0DOI<\/span>:\u00a010.2169\/internalmedicine.1289-18<\/span>.<\/p>\r\n

      14.<\/span>\u00a0Spiegel<\/span>\u00a0J<\/span><\/span>,\u00a0Hellwig<\/span>\u00a0D<\/span><\/span>,\u00a0Becker<\/span>\u00a0G<\/span><\/span>,\u00a0M\u00fcller<\/span>\u00a0M<\/span><\/span>.\u00a0Progressive dementia caused by\u00a0H<\/span>ashimoto\u2019s encephalopathy: Report of two cases<\/span>.\u00a0Eur J Neurol<\/em><\/span>.\u00a02004<\/span>;11<\/span>:711<\/span>\u20133<\/span>.\u00a0DOI<\/span>:\u00a010.1111\/j.1468-1331.2004.00909.x<\/span>.<\/p>\r\n

      15.<\/span>\u00a0Weetman<\/span>\u00a0AP<\/span><\/span>.\u00a0An update on the pathogenesis of\u00a0H<\/span>ashimoto\u2019s thyroiditis<\/span>.\u00a0J Endocrinol Invest<\/em><\/span>.\u00a02021<\/span>;44<\/span>:883<\/span>\u201390<\/span>.\u00a0DOI<\/span>:\u00a010.1007\/s40618-020-01477-1<\/span>.<\/p>\r\n

      16.<\/span>\u00a0Ahmed<\/span>\u00a0OM<\/span><\/span>,\u00a0El-Gareib<\/span>\u00a0AW<\/span><\/span>,\u00a0El-Bakry<\/span>\u00a0AM<\/span><\/span>,\u00a0et al<\/span>.\u00a0Thyroid hormones states and brain development interactions<\/span>.\u00a0Int J Dev Neurosci<\/em><\/span>.\u00a02008<\/span>;26<\/span>:147<\/span>\u2013209<\/span>.\u00a0DOI<\/span>:\u00a010.1016\/j.ijdevneu.2007.09.011<\/span>.<\/p>\r\n

      17.<\/span>\u00a0Hern\u00e1ndez Echebarr\u00eda<\/span>\u00a0LE<\/span><\/span>,\u00a0Saiz<\/span>\u00a0A<\/span><\/span>,\u00a0Graus<\/span>\u00a0F<\/span><\/span>,\u00a0et al<\/span>.\u00a0Detection of 14-3-3 protein in the CSF of a patient with\u00a0H<\/span>ashimoto\u2019s encephalopathy<\/span>.\u00a0Neurology<\/em><\/span>.\u00a02000<\/span>;54<\/span>:1539<\/span>\u201340<\/span>.\u00a0DOI<\/span>:\u00a010.1212\/wnl.54.7.1539<\/span>.<\/p>\r\n

      18.<\/span>\u00a0Chong<\/span>\u00a0JY<\/span><\/span>,\u00a0Rowland<\/span>\u00a0LP<\/span><\/span>,\u00a0Utiger<\/span>\u00a0RD<\/span><\/span>.\u00a0Hashimoto encephalopathy: Syndrome or myth<\/span>.\u00a0Arch Neurol<\/em><\/span>.\u00a02003<\/span>;60<\/span>:164<\/span>\u201371<\/span>.\u00a0DOI<\/span>:\u00a010.1001\/archneur.60.2.164<\/span>.<\/p>\r\n

      19.<\/span>\u00a0Henchey<\/span>\u00a0R<\/span><\/span>,\u00a0Cibula<\/span>\u00a0J<\/span><\/span>,\u00a0Helveston<\/span>\u00a0W<\/span><\/span>,\u00a0et al<\/span>.\u00a0Electroencephalographic findings in\u00a0H<\/span>ashimoto\u2019s encephalopathy<\/span>.\u00a0Neurology<\/em><\/span>.\u00a01995<\/span>;45<\/span>:977<\/span>\u201381<\/span>.\u00a0DOI<\/span>:\u00a010.1212\/wnl.45.5.977<\/span>.<\/p>\r\n

      20.<\/span>\u00a0Castillo<\/span>\u00a0P<\/span><\/span>,\u00a0Woodruff<\/span>\u00a0B<\/span><\/span>,\u00a0Caselli<\/span>\u00a0R<\/span><\/span>,\u00a0et al<\/span>.\u00a0Steroid-responsive encephalopathy associated with autoimmune thyroiditis<\/span>.\u00a0Arch Neurol<\/em><\/span>.\u00a02006<\/span>;63<\/span>:197<\/span>\u2013202<\/span>.\u00a0DOI<\/span>:\u00a010.1001\/archneur.63.2.197<\/span>.<\/p>\r\n

      21.<\/span>\u00a0Forchetti<\/span>\u00a0CM<\/span><\/span>,\u00a0Katsamakis<\/span>\u00a0G<\/span><\/span>,\u00a0Garron<\/span>\u00a0DC<\/span><\/span>.\u00a0Autoimmune thyroiditis and a rapidly progressive dementia: Global hypoperfusion on SPECT scanning suggests a possible mechanism<\/span>.\u00a0Neurology<\/em><\/span>.\u00a01997<\/span>;49<\/span>:623<\/span>\u20136<\/span>.\u00a0DOI<\/span>:\u00a010.1212\/wnl.49.2.623<\/span>.<\/p>\r\n

      22.<\/span>\u00a0Waliszewska-Pros\u00f3\u0142<\/span>\u00a0M<\/span><\/span>,\u00a0Bladowska<\/span>\u00a0J<\/span><\/span>,\u00a0Budrewicz<\/span>\u00a0S<\/span><\/span>,\u00a0et al<\/span>.\u00a0The evaluation of\u00a0H<\/span>ashimoto\u2019s thyroiditis with event-related potentials and magnetic resonance spectroscopy and its relation to cognitive function<\/span>.\u00a0Sci Rep<\/em><\/span>.\u00a02021<\/span>;11<\/span>:2480<\/span>.\u00a0DOI<\/span>:\u00a010.1038\/s41598-021-82281-6<\/span>.<\/p>\r\n

      23.<\/span>\u00a0Waliszewska-Pros\u00f3\u0142<\/span>\u00a0M<\/span><\/span>,\u00a0Ejma<\/span>\u00a0M<\/span><\/span>.\u00a0Assessment of visual and brainstem auditory evoked potentials in patients with\u00a0H<\/span>ashimoto\u2019s thyroiditis<\/span>.\u00a0J Immunol Res<\/em><\/span>.\u00a02021<\/span>;2021<\/span>:3258942<\/span>.\u00a0DOI<\/span>:\u00a010.1155\/2021\/3258942<\/span>.<\/p>\r\n

      24.<\/span>\u00a0Waliszewska-Pros\u00f3\u0142<\/span>\u00a0M<\/span><\/span>,\u00a0Ejma<\/span>\u00a0M<\/span><\/span>.\u00a0Hashimoto encephalopathy-still more questions than answers<\/span>.\u00a0Cells<\/em><\/span>.\u00a02022<\/span>;11<\/span>:2873<\/span>.\u00a0DOI<\/span>:\u00a010.3390\/cells11182873<\/span>.<\/p>\r\n

      25.<\/span>\u00a0Cant\u00f3n<\/span>\u00a0A<\/span><\/span>,\u00a0de F\u00e0bregas<\/span>\u00a0O<\/span><\/span>,\u00a0Tintor\u00e9<\/span>\u00a0M<\/span><\/span>,\u00a0et al<\/span>.\u00a0Encephalopathy associated to autoimmune thyroid disease: A more appropriate term for an underestimated condition?<\/span>\u00a0J Neurol Sci<\/em><\/span>.\u00a02000<\/span>;176<\/span>:65<\/span>\u20139<\/span>.\u00a0DOI<\/span>:\u00a010.1016\/s0022-510x(00)00302-6<\/span>.<\/p>\r\n

      26.<\/span>\u00a0Thrush<\/span>\u00a0DC<\/span><\/span>,\u00a0Boddie<\/span>\u00a0HG<\/span><\/span>.\u00a0Episodic encephalopathy associated with thyroid disorders<\/span>.\u00a0J Neurol Neurosurg Psychiatry<\/em><\/span>.\u00a01974<\/span>;37<\/span>:696<\/span>\u2013700<\/span>.\u00a0DOI<\/span>:\u00a010.1136\/jnnp.37.6.696<\/span>.<\/p>\r\n

      27.<\/span>\u00a0Maas<\/span>\u00a0A<\/span><\/span>,\u00a0Braun<\/span>\u00a0KPJ<\/span><\/span>,\u00a0Geleijns<\/span>\u00a0K<\/span><\/span>,\u00a0et al<\/span>.\u00a0Risks and benefits of rituximab in the treatment of\u00a0H<\/span>ashimoto encephalopathy in children: Two case reports and a mini review<\/span>.\u00a0Pediatr Neurol<\/em><\/span>.\u00a02017<\/span>;66<\/span>:28<\/span>\u201331<\/span>.\u00a0DOI<\/span>:\u00a010.1016\/j.pediatrneurol.2016.09.002<\/span>.<\/p>\r\n

      28.<\/span>\u00a0Drulovi\u0107<\/span>\u00a0J<\/span><\/span>,\u00a0Andrejevi\u0107<\/span>\u00a0S<\/span><\/span>,\u00a0Bonaci-Nikoli\u0107<\/span>\u00a0B<\/span><\/span>,\u00a0Mijailovi\u0107<\/span>\u00a0V<\/span><\/span>.\u00a0Hashimoto's encephalopathy: A long-lasting remission induced by intravenous Immunoglobulins<\/span>.\u00a0Vojnosanit Pregl<\/em><\/span>.\u00a02011<\/span>;68<\/span>:452<\/span>\u20134<\/span>.\u00a0DOI<\/span>:\u00a010.2298\/vsp1105452d<\/span>.<\/p>\r\n

      29.<\/span>\u00a0Nieuwenhuis<\/span>\u00a0L<\/span><\/span>,\u00a0Santens<\/span>\u00a0P<\/span><\/span>,\u00a0Vanwalleghem<\/span>\u00a0P<\/span><\/span>,\u00a0Boon<\/span>\u00a0P<\/span><\/span>.\u00a0Subacute\u00a0H<\/span>ashimoto\u2019s encephalopathy, treated with plasmapheresis<\/span>.\u00a0Acta Neurol Belg<\/em><\/span>.\u00a02004<\/span>;104<\/span>:80<\/span>\u20133<\/span>.<\/p>\r\n

      30.<\/span>\u00a0Orozco<\/span>\u00a0E<\/span><\/span>,\u00a0Valencia-Sanchez<\/span>\u00a0C<\/span><\/span>,\u00a0Britton<\/span>\u00a0J<\/span><\/span>,\u00a0et al<\/span>.\u00a0Autoimmune encephalitis criteria in clinical practice<\/span>.\u00a0Neurol Clin Pract<\/em><\/span>.\u00a02023<\/span>;13<\/span>:e200151<\/span>.\u00a0DOI<\/span>:\u00a010.1212\/CPJ.0000000000200151<\/span>.<\/p>","wpcf-article_received_date":"20230401","wpcf-article_accepted_date":"20230510","wpcf-article_published_online":"20230714","wpcf-podcast":"","wpcf-ogg":"","wpcf-article_end_page":"","wpcf-article_start_page":"","wpcf-acknowledgements":"","wpcf-errata_pdf":"","wpcf-article_flipper_image":"","wpcf-corrected_online":null,"wpcf-supplementary_information":"","wpcf-article_highlight_pdf":"","data_availability":"The datasets generated during and\/or analysed during the current study are available from the corresponding author on reasonable request.","digital_features":""},"_links":{"self":[{"href":"https:\/\/touchneurology.com\/wp-json\/wp\/v2\/posts\/63527"}],"collection":[{"href":"https:\/\/touchneurology.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/touchneurology.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/touchneurology.com\/wp-json\/wp\/v2\/users\/142327"}],"replies":[{"embeddable":true,"href":"https:\/\/touchneurology.com\/wp-json\/wp\/v2\/comments?post=63527"}],"version-history":[{"count":8,"href":"https:\/\/touchneurology.com\/wp-json\/wp\/v2\/posts\/63527\/revisions"}],"predecessor-version":[{"id":72072,"href":"https:\/\/touchneurology.com\/wp-json\/wp\/v2\/posts\/63527\/revisions\/72072"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/touchneurology.com\/wp-json\/wp\/v2\/media\/63587"}],"wp:attachment":[{"href":"https:\/\/touchneurology.com\/wp-json\/wp\/v2\/media?parent=63527"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/touchneurology.com\/wp-json\/wp\/v2\/categories?post=63527"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/touchneurology.com\/wp-json\/wp\/v2\/tags?post=63527"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}