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Altered mental status: what is the diagnosis?
Arjun Gupta1, William Shelton1, Rajeev Singh1
1Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
BMJ Case Reports
|February 14, 2015
Summary
Hashimoto's encephalitis, a reversible neuropsychiatric disorder, can cause altered mental status. Prompt treatment with steroids and plasmapheresis led to rapid improvement in a severe case.
Area of Science:
- Neurology
- Immunology
- Endocrinology
Background:
- Altered mental status necessitates a broad differential diagnosis, particularly when initial investigations for common causes are negative.
- Hashimoto's encephalitis is an underdiagnosed autoimmune encephalopathy with poorly understood mechanisms.
Observation:
- A patient presented with acute neurological decline, including confusion and unresponsiveness, after starting prednisone for suspected autoimmune arthritis.
- Initial workup for the patient's symptoms was unrevealing, but elevated antithyroid peroxidase antibodies were detected.
Findings:
- The patient experienced significant clinical improvement within 24 hours of high-dose steroid therapy and plasmapheresis.
- Elevated antithyroid peroxidase antibody levels (>900 IU/mL) were the key laboratory finding.
Implications:
- This case highlights the importance of considering Hashimoto's encephalitis in patients with unexplained neurological symptoms.
- Early plasmapheresis in conjunction with steroids may be beneficial for severe Hashimoto's encephalitis presentations, especially in patients already on steroids.
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