Autoimmunencephalitis and Psychiatric Symptoms: The Example “SREAT”

Background: Case presentation of a 15-year-old girl who came to us for neuropediatric evaluation after a 4-week stay in a children and youth psychiatry service, treated with an atypical neuroleptic diagnosed with paranoid schizophrenia. Anamnestic presented symptoms were depressive mood, school avoiding behavior, ataxia, formal mental disorder, lack of concentration, “blackouts” as optical and acoustic hallucinations.

Methods: We arranged a long-time EEG, where signs of bitemporal brain function disorder as well as diffuse brain function disorder were shown. A beforehand external performed MRI did not give any signs of pathological findings. During complex investigations we did not find any hints for neurometabolic, neuroinfectiological or neuroinflammatory genesis of the complaints. In 1 year, treatment-required epilepsy or a limbic encephalitis where disassociate seizures occurred could be excluded. Besides a continuous pathological EEG also a positive ANA-screening and positive thyroid antibodies were shown. Therefore, we launched detailed immunological investigations.

Results: After the exclusion of the central course of a lupus erythematodes we diagnosed a Hashimoto thyroiditis with the help of sonography and laboratory chemistry. We had a compulsive presumption of a Hashimoto encephalitis so that a therapy with prednisone 1 mg/kg bw/d was started and increased up to 2 mg/kg bw/d during the course. This resulted in a significant improvement of the patients’ clinical condition, the cortisone therapy was reduced and a year later we saw a nearly complete disappearance of the neurological and psychiatric symptoms. Therefore the diagnosis of a steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT) was made. In retrospect the family reported several family members from the mother`s side that suffered from similar psychiatric symptoms and ataxia.

Conclusion: In a case of psychiatric symptoms, an exclusion of “organic” causes should always be done. SREAT can be treated well. The effectiveness of steroid therapy in Hashimoto thyroiditis can be confirmed. Immunological causes of encephalitis should always be considered. Even in euthyroid metabolism Hashimoto thyroiditis is an option. Complete family history can be groundbreaking in cases of unclear psychiatric, encephalitic symptoms.