A Case of Hashimoto's Encephalopathy Manifesting as Psychosis

Abstract

Two Cases of Somnambulism Induced by QuetiapineSir: Somnambulism reflects an impairment in the normal mechanisms of arousal from sleep in which motor behaviors initiated during deep, non-rapid eye movement or slow-wave sleep are activated without full consciousness. Somnambulism, a previously unreported side effect of quetiapine, is described in 2 cases. Both cases described here involved individuals with attention-deficit/hyperactivity disorder (ADHD). The possible significance of this will be discussed.Case 1. Mr. A, a 52-year-old white man with no history of somnambulism, was undergoing treatment for DSM-IV panic disorder and schizoaffective disorder. He reported attention problems and hyperactivity since childhood and restless legs syndrome for 35 years. He was admitted to the medical unit in February 2006 to rule out myocardial infarction after falling off his porch while sleepwalking.The patient reported that somnambulism had begun 18 months previously, after his quetiapine dose was increased to 200 mg at bedtime. This dose was later titrated to a maximum of 1000 mg during the month prior to admission. At that time, mirtazapine 30 mg at bedtime was added. This combination further aggravated the patient's somnambulism, which occurred almost nightly. The patient was witnessed by his roommate to wander in a confused state, manipulate various belongings, open the refrigerator and eat, and visit the bathroom. He was easily redirected back to bed, but did not appear to awaken.A polysomnogram done when Mr. A was taking 800 mg of quetiapine showed no significant respiratory obstruction. Electroencephalogram (EEG) showed no epileptiform activity. Leg electromyogram findings were significant for frequent leg jerks. Quetiapine treatment was discontinued, and methylphenidate and clonazepam were started. Quetiapine 25 mg nightly was reinitiated later. No recurrence of somnambulism was reported at 8-month follow-up.Case 2. Mr. B, an 18-year-old white man with DSM-IV diagnoses of ADHD and pervasive developmental disorder, sought consultation for episodes of somnambulism and nocturnal combativeness. At the time of presentation in June 2003, he was receiving quetiapine 400 mg nightly and dextroamphetamine sulfate 35 mg daily in divided doses.The patient gave a history of starting quetiapine 8 months previously for onset of command auditory hallucinations. Shortly thereafter, he began to have nightmares associated with shouting, jumping from bed, property destruction, and assaults on family members. Mr. B awakened in the mornings with a headache but had no recollection of the events of the night before.Neurologic examination findings were unremarkable, and results of a 24-hour EEG study were normal. The patient's quetiapine dose was reduced to 350 mg nightly, resulting in the return of auditory hallucinations. Dextroamphetamine sulfate was then tapered over a period of 4 months and discontinued with good result and resolution of hallucinations. The patient continued to have nocturnal outbursts, though these were less frequen...

Hashimoto encephalopathy: literature review

“…HE presents with a wide variety of symptoms that include behavioral changes, confusion, cognitive decline, stroke-like episodes, amnestic syndrome, 16 ataxia, 17 seizures, 18 myoclonus, 19,20 and psychiatric manifestations. 7,21,22 Seizures, including both partial and generalized seizures, 3,23 and myoclonus have been reported to be the most frequent presentations (60-66% of affected patients) in adults. 24 Generalized tonic-clonic seizures are the most common seizures in children followed by partial complex seizures.…”

“…24 Generalized tonic-clonic seizures are the most common seizures in children followed by partial complex seizures. 25 Cognitive impairment (84.6% of affected patients) and psychiatric symptoms (38.5% of affected patients) including depression, 26 mania, 27 psychosis, and hallucinations 7,21,22 have been reported to be additional common symptoms.…”

Hashimoto’s Encephalopathy Presenting with Unusual Behavioural Disturbances in an Adolescent Girl

“…Hashimoto's encephalopathy (HE) is a rare neuroendocrine disorder that may be often misdiagnosed and mistreated for a considerable time. The common neurobehavioural manifestations include seizure-like episodes which are often resistant to anticonvulsive treatment, myoclonus, confusion, headaches, hallucinations, stroke-like episodes, coma, impairment of cognitive function, mood swings, focal neurological deficits, disturbance of consciousness, presenile dementia, psychosis, and ataxia [ 1 , 2 ]. However, such manifestations are not common clinical presentation of HE.…”

Psychiatric Presentations Heralding Hashimoto’s Encephalopathy: A Systematic Review and Analysis of Cases Reported in Literature

“…[16] The electroencephalographic findings showed a normal record in nine patients (19.6%) [17,19,20,23,35,37,46,47] while the most common abnormality noted was an intermittent or diffuse background slowing mostly in the frontal and temporal leads with or without bursts of sharp wave discharge (n = 25.54.3%). [12][13][14]16,18,20,24,[26][27][28][32][33][34]36,39,[41][42][43][44][45]49,50] Magnetic resonance imaging (MRI) returned normal study in 26 patients (56.5%). [14,15,16,17,20,21,[23][24][25][26][27][28]31,32,[36][37][38][39]…”

“…[12][13][14]16,18,20,24,[26][27][28][32][33][34]36,39,[41][42][43][44][45]49,50] Magnetic resonance imaging (MRI) returned normal study in 26 patients (56.5%). [14,15,16,17,20,21,[23][24][25][26][27][28]31,32,[36][37][38][39][41][42][43][44]46,48,50] Of the others whose imaging data were available, the single most common abnormality reported were nonspecific white matter hyperintense lesions (n = 9.19.6%). [12,13,19,32,…”