Hashimoto's encephalopathy is a rare condition, classifiable as an autoimmune non-paraneoplastic encephalopathy. Euthyroid patients can also suffer from this disease. It shows no response to thyroid replacement therapy, but immunosuppressive therapy has proved to be very efficient in treating this disease. Two types of clinical presentation may be observed, the first being characterized by acute onset with focal neurological deficits and epileptic seizures, and the second by non-specific, subacute symptoms such as cognitive impairment, psychiatric disorders, myocloni, and tremor. This paper reports the case of a 63-year old woman referred to a neurologist after being diagnosed with instability while walking, forgetfulness, hand tremor, and headache. Routine laboratory tests and CSF examination showed no abnormalities. Infectious etiology, neurodegenerative and systemic connective tissue diseases were excluded. Paraneoplastic and tumour markers were negative. After eight days, the patient experienced cognitive deterioration, motor dysphasia, ideomotor apraxia, myoclonic jerks of hands with a grand mal epileptic seizure. Antiepileptic treatment was started. Laboratory tests showed normal levels of T3, T4 and TSH with increased levels of anti-TPO and anti-hTG antibodies. Based on these results and AST screening tests (Apraxia Screen of Tulia), the patient was diagnosed with Hashimoto's encephalopathy. Daily treatment was started, with 5 plasmapheresis procedures and corticosteroid therapy. Due to good clinical response, the patient was soon discharged. After two months, due to relapse and the development of tremor, ataxia, dysmetria, and myoclonic jerks, pulse corticosteroid therapy was applied. The patient was discharged home with Medrol oral therapy from which she developed Cushingoid appearance without diabetes or osteoporosis. 18 months later, she developed hypothyroidism and was recommended levothyroxine treatment by an endocrinologist. Presently, neurological assessment is normal. The patient regularly checks up with a neurologist and an endocrinologist. This case report seeks to emphasize consideration of Hashimoto's encephalopathy as a part of differential diagnosis in patients who exhibit atypical neuropsychiatric symptoms, while infectious, paraneoplastic or immune causes of encephalopathy are excluded. Due to the etiology of the disease and side effects of therapy, a multidisciplinary approach in diagnosis and treatment is needed.
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