Title : Cerebral vasculitis in the setting of recurrent hashimoto’s encephalopathy
Abstract:
Introduction:
Hashimoto encephalopathy is a rare autoimmune condition characterized by symptoms such as confusion, seizures, and headache. It can lead to cerebral vasculitis causing the blood vessels in the brain to become inflamed and lead to decreased blood flow with potential for damage to brain tissue.
Case Report:
A 47-year-old male patient was admitted to the hospital with symptoms of a large infarct in the left basal ganglia and scattered punctate infarcts in the right cerebellum. The patient was initially evaluated for potential causes of cardioembolic and hypercoagulable events, but these evaluations were negative.
The patient was started on aspirin and Eliquis for management and showed improvement in physical symptoms, but the patient's depression and abulia worsened over time. Approximately four months after the initial presentation, the patient presented with new stroke-like symptoms. An MRI of the brain revealed severe stenosis of the proximal right middle cerebral artery (MCA), which was a new finding.
The patient was referred to an outpatient neurologist and underwent further testing. A lumbar puncture showed a high white blood cell count of 75, with 76% lymphocytes and positive oligoclonal bands. A four-vessel angiogram was performed and revealed multi-vessel stenosis in large and medium vessels in the brain bilaterally in both the anterior and posterior circulations. This confirmed the presence of cerebral vasculitis.
Based on the patient's positive results for anti-TPO antibody and thyroglobulin antibody, along with his presentation and negative remaining workup, a diagnosis of Hashimoto's encephalitis/encephalopathy was made.
Discussion:
The diagnosis of Hashimoto encephalopathy can be extremely challenging and often presents with symptoms similar to other neurological conditions such as stroke. However, a lumbar puncture (LP) can be helpful. An
additional clue may be imaging studies that show brain atrophy or white matter changes. The treatment of Hashimoto encephalopathy typically involves the use of immunosuppressive medications to reduce inflammation and prevent further damage to the brain.
