Thyroid gland and brain: Enigma of Hashimoto's encephalopathy

Audiovestibular Dysfunction in Patients with Hashimoto's Disease: A Systematic Review

Although the inner ear is considered an immune-privileged organ because of the blood-labyrinth barrier, accumulating evidence has revealed an unexpected relation between Hashimoto's disease and inner ear damage manifesting as audiovestibular dysfunction. Hashimoto's disease can simultaneously affect both the auditory and vestibular systems, either through direct autoantibody attacks or through metabolic dysfunction associated with hypothyroidism. Currently, there is no consensus regarding tests or treatments for audiovestibular dysfunction related to Hashimoto's disease. In this review, we summarize the currently available evidence regarding the characteristics, pathophysiology, diagnostic approaches, and treatment of audiovestibular dysfunction in patients with Hashimoto's disease. Furthermore, we propose a specific steroid-plus-thyroxine treatment protocol to manage audiovestibular dysfunction associated with Hashimoto's disease. This condition may respond to adequate treatment, potentially allowing reversibility if it is recognized and managed in a timely manner. Conversely, delayed diagnosis or failure to recognize the subtle presentation of audiovestibular dysfunction in patients with Hashimoto's disease may lead to progressive hearing loss, immobility, and reduced quality of life. Based on the updated evidence in our review and our modified treatment protocol, we aim to provide new insights and therapeutic directions for clinicians managing audiovestibular dysfunction in patients with Hashimoto's disease. Trial registration: PROSPERO CRD420250652982.

Brain-thyroid crosstalk: 18F-FDG-PET/MRI evidence in patients with follicular thyroid adenomas

OBJECTIVE

The hypothalamic-pituitary-thyroid axis has been well-known. However, whether follicular thyroid adenoma (FTA) could affect brain glucose metabolism is still unknown. Therefore, we explored the brain glucose metabolic characteristics of FTA with Fluorodeoxyglucose F18 positron emission tomography/magnetic resonance imaging.

METHODS

Totally 30 FTA patients without clinical symptoms (FTA group), and 60 age- and sex-matched healthy controls (HC group) were included and randomly divided into cohort A and B in 2:1 ratio. Cohort A was analyzed with scaled sub-profile model/principal component analysis (SSM/PCA) for pattern identification. Cohort B was calculated the individual scores to validate expression of the pattern. Then we calculated the metabolic connectivity based on characteristics of the pattern to investigate the underlying mechanism. Finally, we constructed metabolic brain networks and analyzed the topological properties to further explore the brain metabolic model.

RESULTS

In SSM/PCA, FTA group showed an almost global, left-right symmetrical pattern. In metabolic connectivity, FTA group showed increased metabolic connectivity in brain regions of the sensorimotor network, ventral default mode network (DMN), posterior salient network, right executive control network (ECN), visuospatial network and language network when compared to HC group, and showed decreased connectivity in dorsal DMN and left ECN. In topological properties of brain network, FTA group showed an increased betweenness centrality (BC) in left rolandic operculum, a decreased BC in superior temporal gyrus, increased BC and Degree in right precentral gyrus, increased D in right parahippocampal gyrus and left hippocampus, and decreased D and efficiency in right orbital part of middle frontal gyrus (FDR correction for multiple comparisons, P < 0.05).

CONCLUSION

Although FTA patients are not yet symptomatic, their brain metabolic characteristics include extensive brain alterations, disrupted internal connectivity, not only involving brain regions associated with endocrine activity, but also brain networks and regions associated with motor, emotion and cognition.

Causal effect of three autoimmune diseases on brain functional networks and cerebrospinal fluid metabolites to underlie the pathogenesis of autoimmune psychosis: a two-sample mendelian randomization analysis

BACKGROUND

Autoimmune diseases such as Systemic Lupus Erythematosus (SLE), Sjögren's Syndrome (SS), and Hashimoto's Thyroiditis (HT) frequently exhibit neuropsychiatric manifestations, including cognitive impairment, depression, anxiety, and so on, yet the exact pathogenesis underlying this association remain incompletely understood. Dysfunction of brain resting-state functional networks and cerebrospinal fluid (CSF) metabolite disturbances have been widely reported in psychiatric disorders. However, the application of resting-state functional magnetic resonance imaging (rsfMRI) and CSF metabolomics in the diagnosis and monitoring of autoimmune psychosis is still limited.

METHODS

A two-sample Mendelian randomization (MR) analysis was performed to investigate the causal relationships between three autoimmune diseases (SLE, SS, and HT, n = 14,267 to 402,090 individuals) and 191 rsfMRI phenotypes (n = 47,276 individuals), as well as 338 CSF metabolites. The genome-wide association study (GWAS) of three autoimmune diseases was used as the exposure, whereas rsfMRI phenotypes and 338 CSF metabolites were treated as the outcome. Inverse variance weighted (IVW) with P value < 0.05 was regarded as the primary approach for calculating causal estimates. Additionally, the false discovery rate (FDR)-adjusted P value (PFDR) < 0.05 was utilized to account for multiple testing. MR Egger method, weighted median method, simple mode method and weighted mode method were used for sensitive analysis.

RESULTS

Our analyses identified 5 causal relationships between SLE and the 191 rsfMRI phenotypes, 48 between SS and the 191 rsfMRI phenotypes, and 4 between HT and the 191 rsfMRI phenotypes. Additionally, we found 8 causal relationships between HT and CSF metabolites. Furthermore, all three diseases were significantly associated with the temporal lobe and triple networks (default mode network (DMN), salience network (SN), and central executive network (CEN)), which are the core brain regions and functional networks for cognition. Following FDR correction, 6 causal relationships between SS and the 191 rsfMRI phenotypes were further validated.

CONCLUSIONS

Our study pinpoints important brain functional networks and CSF metabolites potentially implicated in the pathogenesis of psychiatric disorders associated with autoimmune diseases and highlights critical brain regions for the development of novel therapeutics.

Brain Abnormalities in Young Single- and Double-Heterozygote Mice for Both Nkx2-1- and Pax8-Null Mutations

In humans and mice, Nkx2-1 and Pax8 are crucial morphogenic transcription factors defining the early development of the thyroid and specific extrathyroidal tissues. By using 3-month-old single or double heterozygotes for Nkx2-1- and Pax8-null mutations (DHTP) mice, we studied brain abnormalities under different human-like dysthyroidisms, focusing on putative alterations of specific neurotransmitter systems, expression of markers of pre- and post-synaptic function and, given the physio-pathological role mitochondria have in controlling the bioenergetic status of neurons, of mitochondrial dynamics and oxidative balance. Compared to Wt controls, DHTP mice, bearing both systemic and brain hypothyroidism, showed altered expression of synaptic markers, generic and cholinergic (corroborated by immunohistochemistry in caudate, putamen, hippocampus, and basal forebrain) and glutamatergic ones, and reduced expression of key proteins of synaptic plasticity potency and several isoforms of glutamate receptors. The brain of DHTP mice was characterized by lower levels of H2O2 and imbalanced mitochondrial dynamics. Nkx2-1 + / - mice showed dopaminergic neuron-specific alterations, morphologically, more evident in the substantia nigra of DHTP mice. Nkx2-1 + / - mice also showed enhanced mitochondrial biogenesis and oxidative capacity likely as a global response of the brain to Nkx2-1 haploinsufficiency and/or to their elevated T3 circulating levels. Reduced transcription of both tyrosine hydroxylase and dopamine transporter was observed in Pax8 + / - euthyroid mice, suggesting a dopaminergic dysfunction, albeit likely at an early stage, but consistent with the deregulated glucose homeostasis observed in such animals. Overall, new information was obtained on the impact of haploinsufficiency of Pax8 and NKx2-1 on several brain neuroanatomical, molecular, and neurochemical aspects, thus opening the way for future targeting brain dysfunctions in the management of both overt and subclinical thyroid dysfunctions.

Hashimoto's Encephalopathy: Clinical Features, Therapeutic Strategies, and Rehabilitation Approaches

Hashimoto's encephalopathy (HE), also known as steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), is an autoimmune disorder with heterogeneous presentation that poses diagnostic challenges. This review synthesizes the current literature to clarify the clinical, laboratory, and radiological features of SREAT/HE, including the diagnostic utility of thyroid peroxidase (TPO) antibodies, cerebrospinal fluid (CSF) abnormalities, and neuroimaging findings. Cognitive impairment and behavioral changes are common in HE, but specific manifestations vary widely, which can lead to misdiagnosis. While elevated TPO antibodies are frequently observed, a direct causal relationship with HE is unlikely, and their presence may indicate a general state of autoimmunity. Corticosteroids remain the cornerstone of treatment, although responses vary, and alternative immunosuppressive agents or intravenous immunoglobulin may be needed in some cases. Evidence regarding rehabilitation for people affected by HE is limited, but neurorehabilitation strategies adapted from other neurological conditions, including cognitive re-education (CR), physical therapy, and psychosocial support, may be beneficial. Further research is needed to elucidate the underlying mechanisms of SREAT, refine the diagnostic criteria, and develop more targeted and effective therapies, including rehabilitation strategies, for this debilitating neurological disorder.

Clozapine and rapamycin reverse behavioral abnormalities in an animal model of autoimmune schizophrenia

OBJECTIVE

Autoantibody-associated psychosis represents a distinct disease subgroup of patients with schizophrenia with a suspected autoimmune origin. Although preliminary studies have suggested adjunctive drug treatment strategies targeting the immune system, further validation of these findings is warranted. Autoantibodies against SFT2D2 have been identified in patients with schizophrenia. ApoE-/- mice immunized with SFT2D2-peptides can be used as a model for testing immunotherapy in this subgroup of patients. We used the atypical antipsychotic drug clozapine and immunosuppressant rapamycin to test their effects in this mouse model.

METHODS

The mice were evaluated for cognitive and schizophrenia-like behaviors. Following behavioral testing, brain samples were collected for analyzing specific pathological changes and dendritic spine formation.

RESULTS

Clozapine and rapamycin reversed impaired pre-pulse inhibition, motor impairment, and improved cognitive ability in ApoE -/- mice exposed to anti-SFT2D2 immunoglobulin G. Immunohistochemical assays revealed that both clozapine and rapamycin significantly reduced activated microglial infiltration and restored neuronal dendritic spine density.

CONCLUSIONS

Our study results suggested that clozapine and rapamycin possess therapeutic benefits for managing autoimmune psychosis and provide mechanistic insights into immunotherapies involving immunosuppressive agents.

When thyroid met brain: the enigma of steroid responsive encephalopathy associated with autoimmune thyroiditis a case report

Steroid Responsive Encephalopathy Associated with Autoimmune Thyroiditis (SREAT), or Hashimoto's encephalopathy, is a rare autoimmune neurological disorder linked to elevated antithyroid antibodies and presenting various neurological symptoms. This report deals with a case of a 54-year-old female with a history of hypothyroidism who presented with hypertensive emergency and atypical neurological symptoms that deteriorated during the hospital stay. On testing, she was euthyroid. Initial investigations, including MRI and CSF analysis, were inconclusive, but high levels of antithyroid peroxidase (Anti TPO) antibodies confirmed the diagnosis of SREAT. The patient was managed with intravenous methylprednisolone, leading to rapid clinical improvement. SREAT, being a diagnosis of exclusion, presents with various neurological and neuropsychiatric symptoms that can be difficult to identify. This condition remains poorly understood, though autoimmune factors and antithyroid antibodies seem to play a role. Glucocorticoids remain the primary treatment choice. At the same time, other immunosuppressive agents are reserved for non-responders. This case highlights the critical importance of early diagnosis in SREAT, as early recognition and corticosteroid treatment can lead to significant recovery. Timely intervention is essential for improved patient prognosis, emphasizing the need for awareness of SREAT in patients with a history of hypothyroidism presenting with neurological symptoms.

Evaluation of thyroid function tests among children with neurological disorders

Background

Thyroid hormones (THs) are essential for brain development. Numerous studies have identified significant links between thyroid dysfunction and cognitive function. However, research on the significance and necessity of thyroid function tests in diagnosis of neurological disorders is limited and subject to controversy.

Methods

Our study employed a combination of meta-analysis and case-control design. For the meta-analysis, we conducted a systematic search of online databases for studies that compared thyroid function tests in children with neurological disorders to controls. In our case-control study, we recruited a total of 11836 children, comprising 7035 cases and 4801 healthy controls. Wilcoxon Rank Sum Test was used to determine characteristics of thyroid function between the cases and healthy controls. In order to exclude the false discovery rate (FDR), the Benjamini-Hochberg (BH) procedure is applied.

Results

A total of 12 relevant literature sources were included in the meta-analysis. Compared with controls, free thyroxine (FT4) levels were significantly decreased in neurological disorders in meta-analysis (MD = -0.29, 95% CI: -0.50 to -0.09), whereas thyroid-stimulating hormone (TSH) levels showed no significant difference (MD = -0.07, 95% CI: -0.36 to 0.21). In our case-control study, levels of free thyroxine (FT4), total triiodothyronine (TT3), total thyroxine (TT4), and anti-thyroglobulin antibodies (TG-Ab) were notably reduced among individuals with neurological disorders, compared with healthy controls (P<0.001, P<0.001, P=0.036, P=0.006). However, thyroid-stimulating hormone (TSH) levels did not show any statistically significant differences among the cases and controls.

Conclusions

Our research demonstrates that, in comparison to controls, children with neurological disorders exhibited a significant decrease in FT4 levels, while TSH levels remained unchanged. This finding provides a reference for potential serum marker of neurological disorders in children. Replication in future studies with the assessment of THs is needed to determine whether thyroid function should be included as a routine screening in these children.

Predicting thyroid involvement in primary Sjögren's syndrome: development and validation of a predictive nomogram

Introduction

Patients with Primary Sjögren's syndrome (pSS) are at a higher risk of thyroid disorders than the general population. This retrospective analysis of 202 patients with pSS was conducted to uncover risk factors associated with thyroid involvement and to create a predictive model for this condition.

Methods

We analyzed 202 patients with pSS from Guang'anmen Hospital, China Academy of Chinese Medical Sciences, with 105 cases of thyroid involvement and 97 without. The Least Absolute Shrinkage and Selection Operator method was used to identify key variables for our risk model. These variables were then subjected to multivariate logistic regression to develop the model. The accuracy of the model was assessed through the C-index, receiver operating characteristic curves, calibration plots, and decision curve analysis, with internal validation via bootstrapping.

Results

High-sensitivity C-reactive protein (HCRP), pulmonary disease, pharyngeal dryness, forgetfulness, night sweats, hyperuricemia, nasal dryness, anxiety, Ro52, and aspartate aminotransferase (AST) were incorporated into the nomogram. The model showed robust discrimination and calibration abilities. Decision curve analysis indicated the clinical utility of our nomogram in intervening on the probability thresholds of thyroid disease.

Conclusion

By integrating HCRP, pulmonary disease, pharyngeal dryness, forgetfulness, night sweats, hyperuricemia, nasal dryness, anxiety, Ro52, and AST, our thyroid risk nomogram can predict the risk of thyroid involvement in patients with pSS, aiding in more informed treatment strategies.

Association between depression and anxiety disorders with euthyroid Hashimoto's thyroiditis: A systematic review and meta-analysis

Background

Hashimoto's thyroiditis (HT) affects up to 10 % of the population and is a common cause of hypothyroidism, which can lead to depression and anxiety. However, it remains unclear whether HT directly causes these conditions or if they arise due to HT-induced hypothyroidism. The present review aims to offer meta-analytic insights into the relationship between depression and anxiety in patients with euthyroid HT.

Methods

A comprehensive search was conducted in PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang Data, SinoMed, and VIP from their inception through May 2024. Case-control or cross-sectional studies examining the association between euthyroid HT and either depression, anxiety disorders, or both were included.

Results

For depression, 1365 patients (694 HT vs. 671 controls) from 11 articles were analyzed; for anxiety, 1009 patients (516 HT vs. 493 controls) from 8 articles were included. HT patients had 2.5 times higher odds of anxiety disorders (OR = 2.52, 95 % CI: 1.66-3.82). The Beck Depression Inventory showed a WMD of 4.26 (95 % CI: 1.28-7.24) and the Beck Anxiety Inventory a WMD of 5.10 (95 % CI: 1.55-8.66).

Limitation

The findings should be interpreted cautiously due to heterogeneity, potential publication bias, and variability in assessment tools, which may limit generalizability.

Conclusions

Euthyroid HT patients exhibit a higher prevalence of anxiety disorders compared to healthy control groups, and more susceptible to anxiety and depression symptoms based on the Beck Inventory. Thyroid antibodies themselves are also associated with depression and anxiety disorder.

Brain disorders in euthyroid Hashimoto's thyroiditis patients

Hashimoto's thyroiditis (HT) is an autoimmune disorder characterized by the destruction of thyroid follicular cells by thyroid peroxidase antibodies (TPOAb) and thyroglobulin antibodies (TgAb), leading to hypothyroidism. Hashimoto's encephalopathy (HE) is associated with elevated levels of antithyroid antibodies. An important question is whether brain alterations precede the development of HE and are present in euthyroid patients with HT, and what pathomechanisms could be responsible for these changes. A PubMed search was conducted to identify studies addressing this issue. Numerous questionnaire studies confirmed impairments in cognitive functioning, mental and physical health, and overall well-being in euthyroid HT patients. Additionally, some imaging and mouse model studies indicate that euthyroid patients with HT likely have central nervous system alterations. Antibodies may be involved in the development of these changes. Some research suggests the role of TPOAb and TgAb, while other studies highlight the involvement of coexisting antibodies. Determining whether antibodies are assessed in serum or cerebrospinal fluid (CSF) is crucial. Antibody-specific indices (ASIs) can differentiate between antibodies passively diffusing from the serum and brain-derived antibodies, and could serve as biomarkers for brain alterations in HT patients. Much more research is needed to identify reliable biomarkers and treatments that could improve the quality of life for these patients.

Targeting Thyroid-Stimulating Hormone Receptor: A Perspective on Small-Molecule Modulators and Their Therapeutic Potential

TSHR is a member of the glycoprotein hormone receptors, a subfamily of class A G-protein-coupled receptors and plays pivotal roles in various physiological and pathological processes, particularly in thyroid growth and hormone production. The aberrant TSHR function has been implicated in several human diseases including Graves' disease and orbitopathy, nonautoimmune hyperthyroidism, hypothyroidism, cancer, neurological disorders, and osteoporosis. Consequently, TSHR is recognized as an attractive therapeutic target, and targeting TSHR with small-molecule modulators including agonists, antagonists, and inverse agonists offers great potential for drug discovery. In this perspective, we summarize the structures and biological functions of TSHR as well as the recent advances in the development of small-molecule TSHR modulators, highlighting their chemotypes, mode of actions, structure-activity relationships, characterizations, in vitro/in vivo activities, and therapeutic potential. The challenges, new opportunities, and future directions in this area are also discussed.

Association between hypothyroidism subtypes and major depression: A two-sample Mendelian randomization study

BACKGROUND

The causal relationship between different hypothyroidism subtypes and the risk of major depression (MD) is yet to be fully elucidated. This study aimed to determine if there's a causal relationship between various hypothyroidism subtypes (and related factors) and the risk of MD.

METHODS

This genetic association study utilized a two-sample Mendelian Randomization (MR) approach to explore the causal relationships between various hypothyroidism subtypes and MD risk. Genome-Wide Association Study (GWAS) summary statistics were obtained from the FinnGen and the UK Biobank. Instrumental variables (IVs) were chosen based on single nucleotide polymorphisms (SNPs).

RESULTS

Among the analyzed hypothyroidism subtypes and related factors, "Hypothyroidism, strict autoimmune" (HTCBSA) and "Hypothyroidism, levothyroxin purchases" (HT/LP) demonstrated a statistically significant positive causal relationship with MD, with odds ratios of 1.020 (95 % CI: 1.004-1.037) and 1.022 (95 % CI: 1.005-1.040), respectively. The sensitivity analysis supported the robustness of these findings, showing no significant horizontal pleiotropy and confirming the stability of results when individual SNPs were removed. "Congenital iodine-deficiency syndrome/hypothyroidism" (CIDS/HT), "Postinfectious hypothyroidism" (PHT), "Hypothyroidism due to medicaments and other exogenous substances" (HDTDM and OES), "Thyroid Stimulating Hormone" (TSH), "Thyrotropin-releasing hormone" (THRH), and "Hypothyroidism, strict autoimmune, 3 medication purchases required" (HTCBSA/3MPR) showed no significant causal relationship with MD.

LIMITATIONS

The study population was limited to individuals of European ancestry, and there may be certain genetic differences between different ethnic groups.

CONCLUSIONS

This MR study suggests a potential causal relationship between certain hypothyroidism subtypes (specifically HTCBSA and HT/LP) and an increased risk of MD.

The use of intravenous immunoglobulin in the treatment of Hashimoto's encephalopathy: case based review

Background

Hashimoto's encephalopathy (HE) is a controversial immunological neuropsychiatric disease, with a poorly understood pathogenesis. It is characterized by symptoms of acute or subacute encephalopathy which usually occur in the presence of elevated levels of antithyroid antibodies. Even though it is also known as steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT), some cases appear to be steroid-resistant. This review examined whether treatment of Hashimoto's encephalopathy with intravenous immunoglobulin (IVIG) is associated with better clinical outcomes than the standard therapy. Additionally, we presented a case of a 59-year-old man who presented with severe neurological manifestations and was successfully treated with intravenous immunoglobulin.

Methods

The online databases PubMed and EMBASE were searched.

Results

A total of 1,365 articles were identified. After the deletion of 112 duplicates, 1,253 studies were screened by evaluating the title and abstract, focusing on Hashimoto's encephalopathy cases where IVIG were used. 846 studies were excluded because they were not relevant to the topic or included pediatric population. Therefore, 407 full-text articles were assessed for eligibility. The final analysis included 14 eligible articles after 393 were excluded (irrelevant texts, not written in English, full-text not available). In the majority of the selected case-reports, IVIG was associated with a good outcome, sometimes even with dramatic improvements in patient's status.

Conclusion

In last years, intravenous immunoglobulin therapy proved its utility in Hashimoto's encephalopathy's treatment, being a well tolerated therapy associated with remarkable improvement in patient's status. Further research is still needed in order to define the optimal treatment protocol for Hashimoto's encephalopathy and to establish if intravenous immunoglobulin can also be used as a first-line therapy, alone or in combination with steroids.

Cerebellar Ataxia in the Setting of Hashimoto's Thyroiditis: A Case Report Update and Review

Hashimoto's encephalopathy (HE) is a rare diagnosis. Establishing the diagnosis itself is quite challenging, as symptoms vary among cases and there is still no standard confirmatory test. The clinical presentation is heterogeneous; however, patients with HE most commonly experience focal neurological deficits, frequently accompanied by cognitive dysfunction, aphasia, or paresis. The most widely recommended initial treatment for cases of HE is a course of corticosteroids. Nonetheless, their response varies from patient to patient, and some may become resistant to them. There are many proposed second-line treatments; however, there is little data and no consensus on the best alternative treatment when steroid therapy fails. This article provides an update on a case of cerebellar ataxia in a 30-year-old female patient with Hashimoto's thyroiditis. She initially presented with rapid-onset progressive symptoms of cerebellar ataxia (movement incoordination, dysmetria, and balance problems) and had elevated serum anti-thyroid peroxidase antibodies. She was diagnosed with HE and was initially treated with methylprednisolone. However, her symptoms recurred after tapering steroid therapy, and eventually, they ceased to manage her symptoms, plus she developed steroid-induced osteoporosis. She began treatment with intravenous immunoglobulin (IVIG) as an alternative in April 2022. Since then, she has had four infusions of IVIG that have allowed her to remain symptom-free.

Silicone prosthetics and anti-thyroid autoimmunity

INTRODUCTION

In esthetic surgery, the use of silicone implants is a topic of hot discussion.

MATERIAL AND METHODS

An analysis of 119 esthetic surgical interventions on the mammary gland was performed. A study of the immune and endocrine parameters after mammoplasty was carried out.

RESULTS

The phenomenon of an increase in the levels of autoantibodies to the TSH receptor was revealed. The phenomenon of pre-operative growth of prolactin and TSH levels has been confirmed. An increase in thyroid autoimmunity after silicone mammoplasty is interpreted as a result of a silicone adjuvant action. An increase in the incidence of ASIA syndrome in patients who underwent breast surgery was registered. However, it was observed in both patients with silicone and non-silicone breast surgeries and therefore could not be solely explained by the use of silicone. Within 12 months following silicone mammoplasty, the patients with an increase of anti-TSH receptor autoimmunity nevertheless did not show any clinical and laboratory signs of overt thyroid disease, thus staying in a pre-nosological state. PRACTICAL RECOMMENDATIONS: Based on these results, we recommend the following for esthetic surgery: (a) all patients planned for silicone implant surgery should be examined for autoantibodies to the TSH receptor and (b) patients who have undergone breast endoprosthesis, starting 6 months after the operation, need long-term follow-up for thyroid status with mandatory testing for the level of these autoantibodies.

Adaptation and validation of the Hungarian version of Thyroid-Related Patient-Reported Outcome-39 (ThyPro-39) questionnaire: testing factor structure, known-group validity with the comparison of quality of life in Hashimoto's thyroiditis and Graves' disease

BACKGROUND

Living with autoimmune thyroid disease is a longstanding challenge and can seriously affect the quality of life. We aimed to adapt and validate the Hungarian version of the Thyroid-Related Patient-Reported Outcome-39 (ThyPro-39) questionnaire, test its factor structure, and compare two frequent autoimmune thyroid diseases, Hashimoto's thyroiditis, and Graves' disease. We tested the factor structure of ThyPro-39 with a series of confirmatory factor analyses (CFAs). To examine the validity of ThyPro-39 and to compare the quality of life of the two groups - Hashimoto's thyroiditis (N = 240), Graves' disease (N = 51) - CFA with covariates were used.

RESULTS

Our results supported a bifactor model with psychosocial and somatic symptoms as general factors, and 12 symptom-specific factors. Based on the analysis of omega hierarchical indices ranging between 0.22 and 0.66, the specific scales also carry information besides the composite scores and should be used when a more detailed analysis is required. In the multivariate analysis, perceived stress was significantly associated with the general psychosocial factor (β = 0.80), symptom factors (β = 0.34), anxiety (β = 0.43), depressivity (β = 0.37), and emotional susceptibility (β = 0.38) specific factors. Graves' patients reported more eye symptoms (d = 0.45) and cosmetic complaints (d = 0.40), while Hashimoto patients had more cognitive problems (d = 0.36) and more severe hypothyroid symptoms (d = 0.35). These group differences confirm the known-group validity of the questionnaire.

CONCLUSIONS

The validity of the Hungarian version of ThyPRO-39 is supported. We recommend using two composite scores of psychosocial and somatic symptoms and the specific symptoms scores to measure the quality of life in clinical practice and research.

Attenuation of Hypothyroidism-Induced Cognitive Impairment by Modulating Serotonin Mediation

Thyroid hormones play an important role in the modeling of neural networks in the brain. Besides its metabolic effects, thyroid dysfunction, and hypothyroidism in particular, is frequently associated with cognitive decline and depressive-like behavior. The current study aimed to examine the changes in behavior, cognition, and memory in rats with propylthiouracil-induced overt hypothyroidism. The behavior and cognition were assessed using the open field test, T-maze, and novel object recognition test. We found significant differences in the behavioral patterns of the hypothyroid animals showing a reduction in locomotor activity, frequency of rearing, and impaired memory function compared to the euthyroid controls. As serotonin is an essential biomarker regulating cognition and mood, we tried to modulate the serotonin mediation in hypothyroid animals through tryptophan administration. Treatment with 5-hydroxy-tryptophan (5-OH-TRP) intraperitoneally for 10 days or directly into the hippocampus as a single injection led to attenuation of the hypothyroidism-induced cognitive and memory decline. A staggering amount of research is suggesting that the common denominators in the pathophysiology of depression and the behavior changes in hypothyroidism are the hippocampal complex and the distorted serotonin metabolism. In our study, it was observed a significant alleviation of cognitive impairment and an improvement of memory performance in hypothyroid rats after 5-OH-TRP administration. Current results are promising and may serve as groundwork for further investigation of functional and structural changes in the hippocampus during a hypothyroid state, and in particular, the effects of serotonin mediation in hypothyroid-associated depressive-like behavior.

Effects of Excessive Iodine on the BDNF-TrkB Signaling Pathway and Related Genes in Offspring of EAT Rats

Excess iodine can cause autoimmune thyroiditis (AIT) in women, but it is unclear whether this has any implications for neurodevelopmental mechanisms in offspring. We studied the effects of experimental autoimmune thyroiditis (EAT) rats with different amounts of iodine intake on offspring brain development via the brain-derived neurotrophic factor (BDNF)-tropomycin receptor kinase B (TrkB) signaling pathway, because BDNF plays an important role in neurodevelopment. Rats in three thyroglobulin (Tg) immunized groups with varying iodine intakes (Tg (100 µg/L iodine), Tg + High-iodine I group (Tg + HI, 20 mg/L iodine), and Tg + High-iodine II group (Tg + HII, 200 mg/L iodine)) were injected with 800 µg Tg once every 2 weeks for 3 times. Rats in the control group (NI, 100 µg/L iodine) were immunized with saline. Arsenic-cerium catalytic spectrophotometry was used to measure urine iodine levels. The lymphocytic infiltration in the thyroids was observed by histopathological studies. Thyroid autoantibodies levels were measured using radioimmunoassay. The norepinephrine (NE) contents were measured by an enzyme-linked immunosorbent assay. The levels of the BDNF-TrkB signaling pathway and related genes were measured by quantitative real-time PCR and Western blot. Urinary iodine levels increased as iodine intake increased. Lymphocytes were significantly aggravated in Tg-immunized rats. Serum thyroglobulin antibody (TgAb) and thyroid peroxidase antibody (TPOAb) levels were clearly elevated in Tg-immunized rats. Tg-immune groups had significantly lower NE levels. The BDNF-TrkB signaling pathway and related gene mRNA and protein levels were found to be significantly lower in Tg-immune groups with higher iodine levels. Maternal AIT may reduce the levels of certain neurodevelopmental mechanisms in the offspring, such as the BDNF-TrkB signaling pathway and related factors, while excessive iodine consumption by the mother may exacerbate this effect.

Neuropsychiatric Manifestations of Thyroid Diseases

Thyroid disorders are known to cause neuropsychiatric manifestations. Various neuropsychiatric manifestations are depression, dementia, mania, and autoimmune Hashimoto encephalopathy. Numerous investigations carried out in the previous 50-60 years have been evaluated critically. The pathophysiology of neuropsychiatric symptoms of thyroid diseases is described in the current study and its link with autoimmune Hashimoto encephalopathy is also discussed. Furthermore, this paper also describes the association between thyroid-stimulating hormones and cognitive impairment. Hypothyroidism is associated with depression and mania, and hyperthyroidism is linked with dementia and mania. The association between Graves' disease and various mental disorders such as depressive and anxiety disorders is also discussed. The aim of this study is to review the relationship between various neuropsychiatric disorders and thyroid diseases. A literature search from the PubMed database to find various neuropsychiatric manifestations of thyroid disorders in the adult population was conducted. According to the review of the studies, cognitive impairment can result from thyroid disease. It has not been possible to demonstrate how hyperthyroidism can hasten the process of developing dementia. However, subclinical hyperthyroidism, thyroid-stimulating hormone (TSH) levels below the normal range, and high free thyroxine (T4) levels all raise the risk of dementia in the elderly. Additionally, the potential mechanisms underlying this association have been examined. A quick summary of the research on mania as a clinical symptom of hypothyroidism and its likely causes and pathogenesis is also reviewed. There is no dearth of evidence that describes various neuropsychiatric manifestation in thyroid disorders.

Chorea: An unusual manifestation of endocrine diseases

Chorea is a movement disorder involving involuntary movements of muscles of the face, neck, and limbs, usually caused by basal ganglia lesions. As an important part of the presentation of many neurological diseases, chorea is also an unusual manifestation of endocrine diseases and can be challenging to diagnose. Although the most common etiology of chorea is genetic, it is vital to identify acquired or symptomatic chorea, as these are potentially treatable conditions. This review summarizes the latest developments in various endocrine disease-related chorea, which will help clinicians to correctly identify and accurately treat it.

Hashimoto Thyroiditis, but Not Hypothyroidism Due to Other Causes, Is Associated with Lower Phase Angle Score in Adult Women: A Pilot Cross-Sectional Study

PURPOSE

In recent years, Hashimoto's thyroiditis (HT) has become one of the commonest autoimmune diseases. Its clinical symptoms include systemic manifestations related mainly, but not solely, to thyroid hormone deficiency. The bioimpedance phase angle (PhA) is a reliable indicator of nutritional as well as cellular health status. PhA is decreased not only in malnutrition, but also in many inflammatory diseases. The aim of this study was to assess the relationship between HT and PhA score.

METHODS

In this cross-sectional study, we compared the anthropometric, laboratory and body composition parameters of 49 women with HT and 98 propensity-score-matched women without thyroid disease.

RESULTS

Females with HT had significantly lower PhA scores (5.78 ± 0.43) compared to women without a thyroid disorder (5.98 ± 0.49, p = 0.017). Regarding TSH levels, although they were within the normal range in all study participants, in women with HT, they were slightly but significantly higher. Women with HT treated with L-thyroxin had significantly higher PhA compared to their non-treated counterparts. No differences between women with non-HT hypothyroidism and the control group were found.

CONCLUSIONS

Decreased PhA scores in patients with HT may indicate that the inflammatory process in this autoimmune disease has an influence on cellular health and on the function of the entire body. Such an association was not found in women with non-HT hypothyroidism.

Hashimoto Encephalopathy—Still More Questions than Answers

The normal function of the nervous system is conditioned by the undisturbed function of the thyroid gland and its hormones. Comprehensive clinical manifestations, including neurological disorders in Hashimoto’s thyroiditis, have long been understood and, in recent years, attention has been paid to neurological symptoms in euthyroid patients. Hashimoto encephalopathy is a controversial and poorly understood disease entity and the pathogenesis of the condition remains unclear. We still derive our understanding of this condition from case reports, but on the basis of these, a clear clinical picture of this entity can be proposed. Based on a review of the recent literature, the authors present the current view on the subject, discuss controversies and questions that still remain unanswered, as well as ongoing research in this area and the results of our own work in patients with Hashimoto’s thyroiditis.

Hashimoto's encephalopathy with cerebellar ataxia as the main symptom: A case report and literature review

Hashimoto's encephalopathy (HE), also known as steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT), has a variety of clinical manifestations, with various neuropsychiatric characteristics, including tremors, transient aphasia, seizures, altered consciousness, myoclonus, cognitive impairment, and psychiatric manifestations. The hallmark presenting feature is a non-specific encephalopathy characterized by alteration of mental status and consciousness ranging from confusion to coma and impaired cognitive function, while those with cerebellar ataxia as the main manifestation is rare. We reported a case of Hashimoto's encephalopathy with cerebellar ataxia as the main manifestation, elevated anti-thyroid antibodies (anti-TPO/TG), and normal thyroid function. The symptoms of cerebellar ataxia improved after steroid treatment. Meanwhile, we reviewed the clinical features of 20 representative cases of HE with cerebellar ataxia as the core symptoms. In conclusion, based on our case findings and literature review, the diagnosis of HE should be suspected in cases of encephalopathy without an obvious cause, to quickly start an effective treatment.

A Rare Case of Hashimoto’s Encephalopathy With Mosaic Turner Syndrome

Mosaicism in Turner syndrome (TS) is a 20%-30% occurrence, with 45, X plus at least another cell line. The haploinsufficiency of the X chromosome is usually responsible for the higher risk of autoimmunity in TS, exhibiting mainly as thyroiditis, type 1 diabetes, etc. Though Hashimoto’s thyroiditis is commonly seen in patients with TS, the concurrence of encephalopathy in these patients is significantly rare and has not been reported. We present a case of a young female with mosaic TS who presented with altered mental status. The initial workup was negative for stroke and pulmonary embolism and cerebrospinal fluid (CSF) analysis did not show any infectious etiology. Thyroid peroxidase (TPO) antibodies (Abs) and thyroglobulin Abs were elevated. As the patient’s mental status deteriorated, there was a concern for Hashimoto’s encephalopathy (HE), hence the patient was started on high-dose IV steroids. Within 24 hours, the patient responded to the IV steroids and an improvement in mentation was noted. HE is a rare immune-mediated disorder, characterized by impaired brain function. The onset of which can be rapid or slowly developing over the course of many years but responds effectively to steroids. Turner syndrome is associated with a high incidence of autoimmune disorders, thus in the setting of a negative workup for more obvious causes, HE should be a consideration when encountered in a clinical scenario.

Lingering Effects: Hashimoto’s Encephalopathy

Hashimoto's encephalopathy (HE), also known as steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), is a rare autoimmune disease that remains poorly understood. Here, we report a patient who experienced numerous comatose relapses early in the disease course. Despite prolonged corticotherapy, cognitive deficits have persisted through the two-year post-diagnosis follow-up. This case highlights the protracted nature of HE.

Relationship between thyroid hormones and central nervous system metabolism in physiological and pathological conditions

Thyroid hormones (THs) play an important role in the regulation of energy metabolism. They also take part in processes associated with the central nervous system (CNS), including survival and differentiation of neurons and energy expenditure. It has been reported that a correlation exists between the functioning of the thyroid gland and the symptoms of CNS such as cognitive impairment, depression, and dementia. Literature data also indicate the influence of THs on the pathogenesis of CNS diseases, such as Alzheimer's disease, epilepsy, depression, and Parkinson's disease. This review describes the relationship between THs and metabolism in the CNS, the effect of THs on the pathological conditions of the CNS, and novel options for treating these conditions with TH derivatives.

Thyroid Function and Low Free Triiodothyronine in Chinese Patients With Autoimmune Encephalitis

Background and Objectives

Low free triiodothyronine (FT3) is usually associated with worse functional outcome in critical illness; however, the information on thyroid dysfunction and autoimmune encephalitis (AE) is limited. This study aims to evaluate the clinical prognostic value of thyroid function and low-T3 syndrome in patients with multiple subtypes of AE.

Methods

In this retrospective study, we identified the hospital records of 319 candidate patients with AE admitted between January 2016 and December 2020. We then extracted the clinical features and outcomes. Modified Rankin scale (mRS) scores were used to evaluate the patients’ neurological function. The serum levels of FT3, free thyroxine (FT4), and thyroid-stimulating hormone (TSH) were measured upon admission. Normal thyroid stimulating hormone level with FT3 below the lower limit of the reference interval (2.63 nmol/L) was defined as low-T3 syndrome.

Results

A total of 237 AE cases remained after screening. Among these, 57.81% (137/237) were men and the average age at onset was 41 y (interquartile range, 12–61 y). We found that 83.54% (198/237) of the patients had a good prognosis, and 16.46% (39/237) had a poor prognosis. Abnormal thyroid function was observed in 30.80% of these patients, with a relatively greater prevalence in the group with a poor prognosis (p < 0.001). The serum FT3 levels in the poor-prognosis group were significantly lower than those in the good-prognosis group (p < 0.001). Low-T3 syndrome occurred in 15.19% of AE cases and was more frequent in patients with poor prognosis (p < 0.001).

Conclusions

Abnormal thyroid function in AE is frequent, and serum FT3 levels in patients with poor prognosis are significantly lower than in those with good prognosis. Low-T3 syndrome could be a potential candidate for predicting the prognosis of AE following future research.

Pathogenetic mechanisms, clinical signs and consequences of the autoimmune thyroiditis impact on body systems (a literature review)

Background. The review analyzes the publications on the pathogenetic mechanisms and clinical consequences of the impact of autoimmune thyroiditis and hypothyroidism on body systems. Autoimmune thyroiditis is an organ-specific autoimmune disease of the thyroid gland and the most common cause of hypothyroidism in regions of the world with sufficient iodine. Sources of information. The sources of information were reports in domestic and, mostly, foreign periodicals on immunology, pathological physiology, internal medicine, and endocrinology. Synthesis of evidence. The effect of autoimmune thyroiditis on the systems of the body is implemented in two ways. The first one is accomplished through the body’s immune system, when the organ-specific immune process in the thyroid gland for unknown reasons acquires signs of systemic disease with clinical manifestations of damage to other organs and systems. The second is due to hypothyroidism, which is the logical conclusion of the autoimmune process in the thyroid. The effects of hypothyroidism on the body as a whole and its systems, in particular, are known, and the pathogenetic mechanisms are not fully understood and require in-depth study. The issues of the body's autoimmune disease, the mechanisms of its initiation and progression remain undiscovered and poorly understood. Conclusions. The effect of autoimmune thyroiditis is realized through the immune system when the organ-specific immune process in the thyroid gland for unknown reasons acquires signs of systemic disease and hypothyroidism, which is the logical conclusion of the autoimmune process in the thyroid gland. The pathogenetic mechanisms of the effects of autoimmune thyroiditis and hypothyroidism on the body are not fully understood and require in-depth study. The presented data show that over the last decade the interest in studying the problem of autoimmune thyroiditis, hypothyroidism, and their pathological significance for the body has deepened.

Hashimoto’s Thyroiditis Presents as an Acute Encephalopathy: A Case Report of Unusual Presentation

Hashimoto's thyroiditis is the most common thyroid disorder in the United States. Hashimoto encephalopathy is a rare presentation of Hashimoto's thyroiditis that is frequently misdiagnosed.

We present the case of a 71-year-old female who had normal mental status at baseline. She presented with acute alteration in mental status. Further evaluation with brain MRI showed a hyperintense signal in the bilateral centrum. Spinal fluid analysis revealed elevated protein. Thyroid peroxidase (TPO) antibody was elevated at 59.7 and TSH was elevated at 4.9. Her mental status improved dramatically after treatment with steroids and levothyroxine.

This diagnosis should be suspected when the patient develops acute encephalopathy with positive serum thyroid antibody settings with a complete return to normal mental status after treatment with steroids.

Hashimoto's Encephalopathy Masquerading as Rapidly Progressive Dementia and Extrapyramidal Failure

Hashimoto's encephalopathy is a rare immune-mediated disorder characterized by subacute encephalopathy with elevated thyroid antibodies. Hashimoto's encephalopathy is also known as steroid-responsive encephalopathy associated with autoimmune thyroiditis. We report a rare presentation of Hashimoto's encephalopathy presenting with acute neuropsychiatric disturbances, rapidly progressive dementia, seizures, and extrapyramidal failure. Neuroimaging revealed multifocal vasculitides of major cerebral vessels that support the autoimmune vasculitic theory as the underlying pathogenesis for Hashimoto's encephalopathy. Unfortunately, permanent irreversible cerebral damage has already ensued before her presentation to our center, which rendered steroid therapy ineffective. Serological testing for Hashimoto's thyroiditis must be in the investigation of all rapidly progressive dementias as early diagnosis and timely management of autoimmune thyroiditis may salvage sizable and eloquent cerebral tissues. The rarity of the condition should not preclude the investigation of Hashimoto's disease even in the presence of normal levels of thyroid hormones. Delayed diagnosis may result in irreversibly catastrophic encephalopathy in patients who once presented with potentially curable dementia.

Pathophysiology and Clinical Features of Neuropsychiatric Manifestations of Thyroid Disease

Thyroid hormones (TH) have a cardinal role in the development of the central nervous system during embryogenesis and early infancy. However, the TH-responsive genes in the developing brain cease to respond to TH in adulthood. Nevertheless, thyroid dysfunction in adults is commonly associated with a host of cognitive and psychiatric problems. Cognitive decline, dysphoria, and depression are common manifestations of overt hypothyroidism while hyperthyroidism can cause agitation, acute psychosis, and apathy, especially in older people. Whereas levothyroxine treatment can reverse dementia in the setting of hypothyroidism, the effect of levothyroxine on depressive symptoms in subjects with subclinical hypothyroidism is controversial. The use of supraphysiologic doses of TH to treat depression refractory to antidepressant remains a viable therapeutic tool with the caveat that excessive doses of thyroid hormone to treat depression may have potentially damaging effects on other organ systems. The present communication describes the pathophysiology of neuropsychiatric manifestations of thyroid disease, including changes in neurotransmission, alterations in neuronal or glial cell gene expression, blood-brain barrier dysfunction, increased risk of cerebrovascular disease, and occasionally cerebral inflammatory disease in the context of autoimmune thyroid disease. Elucidating the molecular mechanisms of TH effect on cerebral tissue will help identify novel therapeutic targets for managing people with neuropsychiatric disorders.

The Mysterious Universe of the TSH Receptor

The thyroid-stimulating hormone receptor (TSH-R) is predominantly expressed in the basolateral membrane of thyrocytes, where it stimulates almost every aspect of their metabolism. Several extrathyroidal locations of the receptor have been found including: the pituitary, the hypothalamus, and other areas of the central nervous system; the periorbital tissue; the skin; the kidney; the adrenal; the liver; the immune system cells; blood cells and vascular tissues; the adipose tissue; the cardiac and skeletal muscles, and the bone. Although the functionality of the receptor has been demonstrated in most of these tissues, its physiological importance is still a matter of debate. A contribution to several pathological processes is evident in some cases, as is the case of Grave's disease in its multiple presentations. Conversely, in the context of other thyroid abnormalities, the contribution of the TSH-R and its ligand is still a matter of debate. This article reviews the several different sites of expression of the TSH-R and its potential role in both physiological and pathological processes.

First Episode Psychosis and Pituitary Hyperplasia in a Patient With Untreated Hashimoto's Thyroiditis: A Case Report

This case report describes a woman with no psychiatric history and previously diagnosed Hashimoto's thyroiditis who presented to the psychiatric emergency department with a first episode of psychosis. The initial workup for organic causes of psychosis revealed an astronomically high thyroid stimulating hormone (TSH) (> 1,000 μIU/mL) out of proportion to the patient's minimal physical symptoms of hypothyroidism. Additionally the patient's head imaging showed an enlarged pituitary, a rare, but reversible, presentation of chronically untreated primary hypothyroidism. The patient was transferred to a medical unit to receive IV thyroid hormone replacement as well as an adjunctive antipsychotic to assist with remission of her distressing auditory hallucinations and persecutory delusions. This case highlights the importance of a thorough medical workup for causes of new onset psychosis and the need for further consensus in the literature regarding choice of antipsychotic and duration of treatment for psychosis secondary to hypothyroidism.

Thyroid hormones in persons with schizophrenia: A systematic review and meta-analysis

There is accumulating evidence that individuals with schizophrenia show altered levels of thyroid hormones. However, a qualitative and quantitative synthesis of findings in this field has not been performed so far. Therefore, we aimed to perform a systematic review and meta-analysis of studies investigating the levels of thyroid-stimulating hormone (TSH), free thyroxine (fT4), total thyroxine (tT4), free triiodothyronine (fT3) and total triiodothyronine (tT3) in multiple-episode schizophrenia (MES) and first-episode psychosis (FEP). Electronic databases were searched from their inception until 30th May 2020 by two independent reviewers. Random-effects meta-analyses and meta-regression analyses were performed. Altogether, 19 studies were included. Persons with FEP had significantly lower TSH levels (5 studies, g = -0.26, 95%CI: -0.47 to -0.06, p = 0.013, I² = 21.3%), higher fT4 levels (3 studies, g = 0.58, 95%CI: 0.15-1.01, p = 0.008, I² = 64.6%) and lower tT3 levels (2 studies, g = -0.60, 95%CI: -0.82 to -0.37, p < 0.001, I² = 0%) compared to controls. Elevated TSH levels were found in persons with MES (13 studies, g = 0.20, 95%CI: 0.02-0.39, p = 0.031, I² = 50.0%). Our findings imply that the levels of TSH might be decreased in persons with FEP and increased in those with MES. Other alterations need to be confirmed by additional studies. These findings imply the need to monitor the levels of TSH and thyroid hormones from the onset of psychosis.

The value of color Doppler ultrasound in the diagnosis of thyroid nodules: a systematic review and meta-analysis

BACKGROUND

This study aimed to analyze the value of color Doppler ultrasound in the diagnosis of thyroid nodules.

METHODS

We searched the PubMed, Web of Science, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) on using color Doppler ultrasound, thyroid nodules, thyroid tumors, and Doppler ultrasound to diagnose the thyroid nodules. The outcome indicators in the articles had to include the numbers of true positives (TP), false positives (FP), false negatives (FN), and true negatives (TN). Subsequently, the Jadad tool was adopted to evaluate the quality of the included articles, and Review Manager 5.3 software was used to conduct a meta-analysis of the experimental data.

RESULTS

A total of eight suitable articles were selected. The results showed that the estimated sensitivity and specificity of color Doppler ultrasound for the diagnostic of thyroid nodules were 0.46-0.89 and 0.00-1.00, respectively. The pooled estimate of sensitivity for the different articles was 0.71 [95% confidence interval (CI): 0.46-0.89], and the pooled estimate of specificity was 0.77 (95% CI: 0.00-1.00). The area under the summary receiver operating characteristic (SROC) curve (AUC) was 0.917, which was larger than 0.9, signifying high diagnostic accuracy. This suggests that color doppler ultrasound can realize the clinical diagnosis of thyroid nodules.

DISCUSSION

In summary, the results of this study could provide a clinical data for the promotion and application of color Doppler ultrasound in the clinical diagnosis of thyroid nodules, as well as further reliable data for follow-up clinical research on the diagnosis and treatment of thyroid nodules.

Long-term low-dose oxytetracycline potentially leads to neurobehavioural changes

Trace levels of oxytetracycline (OTC)-a veterinary antibiotic and feed additive-are widespread in the environment. Studies revealed that OTC potentially impairs thyroid function, which may affect neurobehaviour; however, the impact of exposure to environmental concentrations of OTC on adult neurobehaviour is unknown. In this study, the effects of OTC on zebrafish after 30-day exposure were investigated. The total swimming distance was significantly increased under vibration and light/dark stimulation, while time spent in the white area was prolonged during the black/white preference test, indicating that the zebrafish became bolder and more impulsive under low OTC exposure. Additionally, monoamine neurotransmitter (5-hydroxytryptamine, dopamine, norepinephrine) levels were decreased and gene expression of monoamine oxidase (mao) involved in neurotransmitter metabolism was upregulated at the transcription level after OTC exposure. Because triiodothyronine (T3) levels were enhanced following exposure to OTC, we speculated that T3 may mediate OTC damage to the nervous system. Our simulated molecular docking analysis showed that OTC combined with the sodium iodide cotransporter protein may result in excessive T3 synthesis. We further exposed zebrafish to T3, and they exhibited similar behaviour to the OTC exposure group. In conclusion, environmental OTC may activate monoamine oxidase and enhance the metabolism of monoaminergic neurotransmitters via T3, thereby inducing abnormal neurobehaviour.

Autoantibody-associated psychiatric symptoms and syndromes in adults: A narrative review and proposed diagnostic approach

Background

Autoimmune-mediated encephalitis is a disease that often encompasses psychiatric symptoms as its first clinical manifestation’s predominant and isolated characteristic. Novel guidelines even distinguish autoimmune psychosis from autoimmune encephalitis. The aim of this review is thus to explore whether a wide range of psychiatric symptoms and syndromes are associated or correlate with autoantibodies.

Methods

We conducted a PubMed search to identify appropriate articles concerning serum and/or cerebrospinal fluid (CSF) autoantibodies associated with psychiatric symptoms and syndromes between 2000 and 2020. Relying on this data, we developed a diagnostic approach to optimize the detection of autoantibodies in psychiatric patients, potentially leading to the approval of an immunotherapy.

Results

We detected 10 major psychiatric symptoms and syndromes often reported to be associated with serum and/or CSF autoantibodies comprising altered consciousness, disorientation, memory impairment, obsessive-compulsive behavior, psychosis, catatonia, mood dysfunction, anxiety, behavioral abnormalities (autism, hyperkinetic), and sleeping dysfunction. The following psychiatric diagnoses were associated with serum and/or CSF autoantibodies: psychosis and schizophrenia spectrum disorders, mood disorders, minor and major neurocognitive impairment, obsessive-compulsive disorder, autism spectrum disorders (ASD), attention deficit hyperactivity disorder (ADHD), anxiety disorders, eating disorders and addiction. By relying on these symptom clusters and diagnoses in terms of onset and their duration, we classified a subacute or subchronic psychiatric syndrome in patients that should be screened for autoantibodies. We propose further diagnostics entailing CSF analysis, electroencephalography and magnetic resonance imaging of the brain. Exploiting these technologies enables standardized and accurate diagnosis of autoantibody-associated psychiatric symptoms and syndromes to deliver early immunotherapy.

Conclusions

We have developed a clinical diagnostic pathway for classifying subgroups of psychiatric patients whose psychiatric symptoms indicate a suspected autoimmune origin.

•

Autoantibodies are associated with a broad spectrum of psychiatric syndromes.

•

More systematic studies are needed to elucidate the significance of autoantibodies.

•

We developed a pathway to identify autoantibody-associated psychiatric syndromes.

An observational study on the association of anti-thyroid autoantibodies with clinical, EEG, MRI, FDG-PET, cerebrospinal fluid and anti-neuronal antibody findings in 530 patients with schizophreniform and affective disorders

INTRODUCTION

Although the link between autoimmune thyroiditis and mental illnesses is well established, the precise underlying pathophysiology and the influence of anti-thyroid antibodies on diagnostic findings require further research.

PATIENTS AND METHODS

A total of 530 patients with schizophreniform and affective syndromes were screened for anti-thyroid antibodies against thyroid peroxidase (TPO), thyroglobulin (TG), and thyroid-stimulating hormone receptor (TSH-R). The patient group analyzed here is a patient subgroup of a previously published cohort (Endres et al., 2020, Translational Psychiatry). The anti-thyroid antibody positive (N = 91) and negative (N = 439) patients were compared in terms of various clinical parameters, routine cerebrospinal fluid (CSF) findings, and the number of positive anti-neuronal antibodies in serum and/or CSF, as well as electroencephalography (EEG), magnetic resonance imaging (MRI), and ^[18 F]fluorodeoxyglucose positron emission tomography (FDG-PET) findings.

RESULTS

Anti-TPO antibodies were increased in 17%, anti-TG antibodies in 15%, and anti-TSH-R antibodies in 2% of all patients. In CSF, higher protein concentrations (p = 0.018) and albumin quotients (p = 0.008) were found in the anti-thyroid antibody positive patient group. Also, there were more patients with elevated age-corrected albumin quotients in this group (p = 0.031). FDG-PET hypometabolism was significantly more frequent and the number of positive anti-neuronal intracellular antibodies was significantly higher in patients with anti-thyroid antibodies (p = 0.048, N = 29 and p = 0.032, N = 497 respectively). In addition, there was a trend for higher white blood cell (WBC) counts in all patients with anti-thyroid antibodies (p = 0.090). In the patient subgroup with anti-TPO antibodies this difference was statistically significant (p = 0.027). No relevant differences were found in the other CSF routine parameters, the number of anti-neuronal antibodies against cell surface antigens in serum and/or CSF, EEG and MRI findings.

DISCUSSION

The present study provides evidence of impaired blood CSF barrier (BCSFB) function in patients with anti-TPO and anti-TG antibodies. An influence of anti-TG antibodies on BCSFB structures has been shown in previous laboratory studies, which reported that the antibodies bind to vascular smooth muscle cells. Due to BCSFB breakdown anti-thyroid antibodies might lead to increased autoimmune susceptibility. The alterations in the FDG-PET, WBC count, and anti-neuronal antibody findings against intracellular structures indicate that it could be useful to extend diagnostic investigations in patients with anti-thyroid antibodies. Further studies should investigate whether anti-thyroid antibodies can also act as "drivers of disease".

The Role of Thyroid Function in Alzheimer's Disease

The thyroid gland is crucial for the regulation of metabolism, growth, and development of various tissues, organs, systems, including the central nervous system. Recent studies have implicated the role of thyroid dysfunction in the etiology of Alzheimer's disease (AD), while AD leads to a significant increase in the prevalence of thyroid dysfunction. In this review, we have analyzed the role of thyroid function in the pathophysiology of AD as well as its biomarkers. The present review aims to provide encouraging targets for early screening of AD risk factors and intervention strategies.

Alpha-enolase involvement in intestinal and extraintestinal manifestations of celiac disease

Celiac disease is a life-long intestinal autoimmune disease, characterized by the gluten intolerance and chronic enteric inflammation. Traditionally presented by intestinal manifestations, however, a shift toward extra intestinal presentation is taking place. One of the affected organs is the nervous systems presented by neuropsychiatric manifestations, hence the mechanism and pathways are not clear. The presence of neuronal and alpha-enolases and their corresponding antibodies were noticed in the mucosa and serum of celiac disease patients, as well as in other various autoimmune diseases with psycho-neurological manifestations. The aims of the present review are to screen the literature on different isoforms of enolase, mainly alpha enolase, and their specific antibodies and to suggest their potential pathophysiological mechanisms relaying the enolases to intestinal or extraintestinal celiac disease manifestations. The shared aspects between the enolases and celiac disease and the cross-talks between alpha-enolase and tissue transglutaminase suggest new potential pathophysiological mechanisms that might drive celiac disease evolvement.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis with Serum Anti-Thyroid Antibodies: A Case Report and Literature Review

BACKGROUND Anti-N methyl D-aspartate receptor encephalitis (anti-NMDArE) is a disorder in which triggers such as infectious agents or neoplastic disease can lead to an autoimmune response against the nervous system, although this disorder is usually idiopathic. Some patients with anti-NMDArE have evidence of other autoimmune alterations. Here, we present a case of non-paraneoplastic anti-NMDArE with elevation of serum anti-thyroid antibodies and a literature review of this association. CASE REPORT A 16-year-old girl was admitted in the University Hospital of Bari for a new onset of tonic-clonic seizures. Progressively, the patient manifested also psychomotor agitation, language difficulties, memory impairment, psychotic symptoms, autonomic dysfunction, and psychomotor retardation. Blood evaluation revealed the presence of anti-thyroglobulin, anti-thyroperoxidase, and anti-NMDAr antibodies. Cerebrospinal fluid analysis confirmed the diagnosis of anti-NMDArE. No tumors were found. Treatment with intravenous immunoglobulin, steroids, and plasma exchange relieved symptoms and decreased levels of serum anti-NMDAr antibodies. After 12 months, the patient had full recovery of communicative capacity, with the persistence of slight difficulty of memory and mild tendency to irritability. Blood exams shown persistence of anti-NMDAr positivity and absence of anti-thyroid antibodies. CONCLUSIONS We report a rare case in which an autoimmune involvement of thyroid gland was concurrent with an anti-NMDArE. It would be useful for clinical practice to clarify whether the presence of anti-thyroid antibody an characterize the clinical course, prognosis, and response to treatment of the idiopathic type of anti-NMDArE.

Persisting symptoms in patients with Hashimoto's disease despite normal thyroid hormone levels: Does thyroid autoimmunity play a role? A systematic review

OBJECTIVE

Patients with hypothyroidism due to Hashimoto's disease (HD) may experience persisting symptoms despite normal serum thyroid hormone (TH) levels. Several hypotheses have been postulated to explain these persisting symptoms. We hypothesized that thyroid autoimmunity may play a role.

DESIGN

A systematic literature review.

METHODS

A PubMed search was performed to find studies investigating the relation between the presence of thyroid autoimmunity and (persisting) symptoms. Included studies were critically appraised by the Newcastle - Ottawa Scale (NOS) and then subdivided into (A) disease-based studies, comparing biochemically euthyroid patients with HD, and euthyroid patients with non-autoimmune hypothyroidism or euthyroid benign goitre, and (B) (general) population-based studies. Due to different outcome measures among all studies, meta-analysis of data could not be performed.

RESULTS

Thirty out of 1259 articles found in the PubMed search were included in this systematic review. Five out of seven disease-based studies found an association between thyroid autoimmunity and symptoms or lower quality of life (QoL). Sixteen of 23 population-based studies found a comparable positive association. In total, the majority of included studies reported an association between thyroid autoimmunity and persisting symptoms or lower QoL in biochemically euthyroid patients.

CONCLUSION

(Thyroid) autoimmunity seems to be associated with persisting symptoms or lower QoL in biochemically euthyroid HD patients. As outcome measures differed among the included studies, we propose the use of similar outcome measures in future studies. To prove causality, a necessary next step is to design and conduct intervention studies, for example immunomodulation vs. placebo preferably in the form of a randomized controlled trial, with symptoms and QoL as main outcomes.

The evaluation of Hashimoto's thyroiditis with event-related potentials and magnetic resonance spectroscopy and its relation to cognitive function

Thyroid dysfunction is very often accompanied by cognitive and affective disorders. The frequency of these disorders in patients with compensated Hashimoto's thyroiditis (HT) is unknown. The aim of the present study was to evaluate brain dysfunction in euthyroid HT patients by means of event-related potentials (ERP) and magnetic resonance spectroscopy (MRS) and to correlate it with cognitive function. 68 patients with HT (59 female, 9 male) and 45 healthy controls were included in the study. All the patients underwent ERP including an analysis of N200 and P300 response parameters. MRS voxels were located in the posterior cingulate gyrus (PCG) and the left parietal white matter (PWM). The NAA/Cr, mI/Cr, and Cho/Cr ratios were analysed. The ERP parameters, MRS metabolite ratios and hormonal concentrations (TSH, fT3, fT4) as well as TGAb and TPOAb titer were also correlated. There was a significant prolongation of the latencies of N200 and P300 potentials and a significant decrease of P300 amplitude in HT patients than in the control group. There was a significant positive correlation between the mI/Cr ratio in the PCG area and P300 latencies. NAA/Cr ratio in the PCG region showed significant negative correlations with all N200 latencies. The results may suggest brain dysfunction in neurologically asymptomatic HT patients. ERPs undergo significant changes in patients with HT and may, in combination with MRS, constitute an important element in the recognition and monitoring of cognitive functions in this group of patients.

Endocrine dysfunction and cognitive impairment

Dementia is a highly prevalent chronic disease among the older population, affecting more than 50 million people worldwide and representing a huge healthcare, social and economic burden. Dementia, and in particular Alzheimer's disease, prevalence is expected to raise within the next few years. Unfortunately, no disease-modifying therapies are available so far, despite a plethora of clinical trials targeting the hallmarks of Alzheimer's disease. Given these premises, it appears crucial to address not only the neuropathological correlates of the disease, but also the modifiable risk factors. Among them, evidence suggest a role of the endocrine system not only in the brain development, but also in the maintenance of its health, having neurotrophic, antioxidant and metabolic functions crucial for the cognitive abilities. This review focuses on the evidence evaluating the impact of the endocrine systems, in particular thyroid function, insulin resistance, parathyroid hormone, vitamin D and sexual hormones on cognitive status. Results from epidemiological, preclinical and some clinical studies demonstrated the link between thyroid, parathyroid hormone and vitamin D and cognitive status, between diabetes, and insulin resistance in particular, and dementia, between sexual and adrenal hormones, particularly estrogen variation at menopause, and cognitive decline. The growing interest on the modifiable risks factors of cognitive decline increased the knowledge about the complex interplay of endocrine systems and cognition, highlighting the need and the usefulness of a multidisciplinary approach to the prevention of a complex and devastating disease.

Hashimoto Encephalopathy in Pediatrics: Report of 3 Cases

OBJECTIVE

To describe the rare occurrence of pediatric Hashimoto encephalopathy in 3 patients.

METHODS

The patients, 9 to 13 years of age, presented with new-onset seizures and other neurologic symptoms, including hemiplegia, aphasia, and memory loss. Thyroid function tests and thyroid antibodies were measured. Magnetic resonance imaging (MRI) of the brain, cerebrospinal fluid analysis, and electroencephalography were also performed.

RESULTS

The first patient had a thyroid-stimulating hormone (TSH) level of 60 μIU/mL (range, 0.4-4.5), free T4 of 0.28 ng/dL (range, 0.7-1.6), and thyroid peroxidase antibody (TPO Ab) of 1243 IU/mL (range < 9). The MRI results indicated a hyperintense signal along the gyri and sulci with diffuse leptomeningeal enhancement bilaterally. The second patient had a TSH level of 25 μIU/mL, free T4 level of 0.7 ng/dL, and TPO Ab level of 3340 IU/mL. The MRI result was normal. The third patient, who was already on levothyroxine, had a TSH level of 17 μIU/mL, free T4 level of 0.81 ng/dL, and TPO Ab level of 1200 IU/mL. The MRI result was normal. All patients had significant elevation of protein in the cerebrospinal fluid and background slowing on electroencephalography. All patients were treated with high doses of intravenous methylprednisolone followed by oral prednisone and thyroid hormone replacement.

CONCLUSION

These cases underscore the importance of thyroid function tests with antibodies in children presenting with acute neuropsychiatric manifestations, especially new-onset seizures without any identifiable cause. We believe that this condition is underdiagnosed in children, and a high index of suspicion is recommended.

Patients with a relapsing course of steroid-responsive encephalopathy associated with autoimmune thyroiditis exhibit persistent intrathecal CD4+ T-cell activation

BACKGROUND AND PURPOSE

Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) is a rare condition defined by encephalopathy with acute or subacute onset, the presence of serum anti-thyroid antibodies, and reasonable exclusion of alternative causes. Despite having strong response towards corticosteroid treatment, some patients exhibit a chronic-relapsing course and require long-term immunosuppression. Markers for early identification of those patients are still absent. Thus, we aimed to characterise clinical as well as laboratory parameters of our local SREAT cohort.

METHODS

We retrospectively evaluated a cohort of 22 SREAT patients treated in our hospital from January 2014.

RESULTS

A total of 14 patients with a monophasic disease course and eight patients with multiple relapses were identified. Neither baseline characteristics nor routine cerebrospinal fluid (CSF) parameters were able to distinguish between those patient groups. Flow cytometry following initial relapse therapy showed treatment-resistant sequestration of activated CD4+ T cells in patients with a relapsing disease course, whereas other lymphocyte subsets showed uniform changes. Such changes were also present in long-term follow-up CSF examination.

CONCLUSION

Our findings indicate a potential biomarker for risk stratification in patients with SREAT. Currently, it remains unclear whether the observed two phenotypes are different spectra of SREAT or represent separate diseases in terms of pathophysiology.

Association between acute disseminated encephalomyelitis and thyroid autoimmunity in children

BACKGROUND

Abnormal thyroid peroxidase antibody (TPOAb) levels are observed in various autoimmune diseases. However, the relationship between TPOAb and pediatric acute disseminated encephalomyelitis (PADEM) remains unclear. This study aimed to investigate the positive rate of TPOAb and thyroid dysfunction in children with acute disseminated encephalomyelitis (ADEM) and assess the relationship between TPOAb and clinical features of PADEM.

METHODS

This retrospective single-center case-control study was conducted from April 2017 to April 2019. We enrolled 23 children with ADEM and 23 age- and sex-matched healthy controls. Based on whether they were positive for TPOAb, the children with ADEM were allocated either to the TPOAb+ or TPOAb- group. The median follow-up time was 12 months (6-30 months). Observers were blinded to the patient groupings. We compared the clinical and imaging characteristics of the two groups.

RESULTS

Among the 23 patients with PADEM, 47.8% presented with abnormal TPOAb levels, while there were no TPOAb+ cases in the control group. Among the children with ADEM, there were significantly increased TPOAb positive rates and significantly decreased fT3 levels. TPOAb+ and TPOAb- subgroup analysis revealed significant differences in gait, fever, and total IgG. In the TPOAb+ group, there was a significant decrease in TPOAb levels at 2 weeks after ADEM onset. The follow-up of patients who were TPOAb+ at 3 months after onset showed a gradual decrease in their TPOAb levels back to normal. One patient who presented new nervous system symptoms after over 1 month also showed a simultaneous increase in TPOAb levels. There was a significant negative correlation between Glasgow Coma Scale (GCS) scores and TPOAb levels (p = 0.042, r = -0.892).

CONCLUSION

There was a negative correlation of TPOAb levels with GCS scores. Therefore, TPOAb levels could be used for the prognosis of patients with PADEM. We recommend determining thyroid function when assessing patients with PADEM during follow-up.