An organic cause of neuropsychiatric illness in adolescence

Medicinal-Induced Behavior Disorders

Commonly used medications can have neuropsychiatric and behavioral effects that may be idiosyncratic or metabolic in nature, or a function of interactions with other drugs, toxicity, or withdrawal. This article explores an approach to the patient with central nervous system toxicity, depending on presentation of sedation versus agitation and accompanying physical signs and symptoms. The effects of antihypertensives, opioids, antibiotics, antiepileptic agents, steroids, Parkinson's disease medications, antipsychotics, medications for human immunodeficiency virus infection, cancer chemotherapeutics, and immunotherapies are discussed. A look at the prevalence of adverse reactions to medications and the errors underlying such occurrences is included.

Hashimoto's encephalopathy: A long-lasting remission induced by intravenous immunoglobulins

Background. Hashimoto's encephalopathy (HE) is a rare autoimmune syndrome characterized by various neuropsychiatric manifestations, responsive to steroid treatment and associated with Hashimoto's thyroiditis. There are only a few reports suggesting that intravenous immunoglobulins (IVIG) might represent an efficacious treatment modality for the severe steroid-resistant HE cases. We presented a patient with HE who developed a complete recovery after the IVIG therapy followed by a long-lasting remission. Case report. We described herien a female patient with the one-year history of autoimmune thyroiditis before the development of neuropsychiatric manifestations. In May 1999, a 38-year-old woman presented at the Institute of Neurology, Clinical Center of Serbia, Belgrade, with the brain-stem syndrome which responded well to steroid treatment. After detailed examinations, the diagnosis of Hashimoto's encephalopathy was established. Two years later, in June 2001, new manifestations (unsteadiness in gait, personality changes, seizures, and persistent headache) gradually developed during a 6-month period. Response to steroids was unsatisfactory and partial, since headaches and personality changes had continuously worsened. In January 2002, the patient received IVIG (0.4 g/kg body weight daily for 5 days). Gradual improvement was noticed and a complete recovery developed over the following weeks. Up to March 2009, during a 7-year follow-up period, remission persisted. Conclusion. To our best knowledge, this is the first report of a long-lasting remission of Hashimoto?s encephalopathy after IVIG therapy. Therefore, this case further supports administration of IVIG, as a potentially beneficial treatment modality, in severe cases of Hashimoto's encephalopathy which are completely or partially resistant to steroids.

Unexplained seizures, confusion or hallucinations: think Hashimoto encephalopathy

AIM

Hashimoto encephalopathy (HE) is a serious but treatable condition that is probably underdiagnosed. We summarize and review all published cases to delineate the disease and to alert paediatricians so that they recognize the disease in children.

METHODS

We searched three data sources, PubMed, Cochrane and Embase, to find the articles on the subject.

RESULTS

Twenty-five children (85.8% girls) were reported being diagnosed with HE. The median age was 14 years (range 9-18 years). The most frequent clinical symptoms were seizures (80%), confusion (52%), headache (40%), hallucinations (32%) and ataxia (36%). Antimicrosomal antibodies were demonstrated in all patients, other diagnostic methods were not specific. Treatment with steroids was effective with 55% of patients showing complete recovery.

CONCLUSION

We recommend measuring antimicrosomal antibodies in all children with unexplained seizures, hallucinations or confusion and, if positive, initiating treatment with prednisolone.

The neurological disorder associated with thyroid autoimmunity

The neurological disorder associated with thyroid autoimmunity is an elusive disease that neurologists have learned to recognize in the last few years. The diagnosis is made, after excluding more common diseases, when neuropsychiatric symptoms develop in a patient with high serum concentrations of anti-thyroid antibodies. The clinical presentations of the disease and the many controversial issues surrounding the diagnosis, the pathogenesis, the role of thyroid autoantibodies, and the choice of therapy are reviewed and discussed in the light of the medical literature in English.

Paediatric Liaison Work by Child and Adolescent Mental Health Services

BACKGROUND

  Although psychiatric morbidity is common amongst paediatric patients, little is known about the availability of CAMH paediatric liaison services.

METHOD

  We surveyed all Trusts with specialist CAMH services and paediatric units in Greater London, enquiring about the nature of liaison that CAMHS provide.

RESULTS

  We found that although liaison paediatric work was common, dedicated paediatric liaison services were provided by only a minority of specialist multidisciplinary CAMHS. Their work involved most aspects of child psychopathology, and included emergencies and children with joint physical and psychiatric problems. About 2/3 of paediatricians were satisfied with CAMHS liaison services, but virtually all desired to see them developed further. There were few indications of co-ordination between specialist multidisciplinary CAMHS and other paediatric psychosocial support services.

Clinical and diagnostic aspects of encephalopathy associated with autoimmune thyroid disease (or Hashimoto's encephalopathy)

Encephalopathy associated with autoimmune thyroid disease, currently known as Hashimoto's encephalopathy, but also defined as corticosteroid-responsive encephalopathy associated with autoimmune thyroiditis, is a relatively rare condition observed in a small percentage of patients presenting with autoimmune thyroid disease. It consists of a subacute, relapsing-remitting, steroid-responsive encephalopathy characterised by protean neurologic and neuropsychiatric symptoms, diffuse electroencephalographic abnormalities and increased titres of antithyroid antibodies in serum and/or in cerebrospinal fluid. Most of the cases presenting this neurologic complication are affected by Hashimoto's thyroiditis or, less frequently, by other autoimmune thyroid diseases, chiefly Graves' disease. The pathogenesis of this encephalopathy is still unknown and largely debated, because of extremely varied clinical presentation, possibly referable to different aetiologic and pathophysiologic mechanisms, as confirmed by the two clinical cases we report in this paper. Autoimmune aetiology is, however, very likely in view of the well established favourable response to corticosteroid administration. Both vasculitis and autoimmunity directed against common brain-thyroid antigens represent the most probable aetiologic pathways. Clinical manifestations include consciousness changes, neurologic diffuse or focal signs, headache, and altered cognitive function. Although unspecific, cerebral oedema has also been described. Cerebrospinal fluid examination often discloses an inflammatory process, with a mild increase in protein content and occasionally in lymphocyte count. In this review, clinical criteria for the diagnosis of defined, probable, or possible encephalopathy associated with autoimmune thyroid disease are suggested. Corticosteroid therapy currently allows us to obtain rapid remission of disease symptoms, but adverse outcomes as well as spontaneous remissions have also been reported.

Encephalopathy associated with Hashimoto thyroiditis: pediatric perspective

In recent years, neuropsychiatric symptoms associated with Hashimoto thyroiditis have been increasingly recognized in both adult and pediatric patients. This neurologic complication has been termed "Hashimoto encephalopathy," and it can begin abruptly, in the form of seizures or agitation, with or without other neurologic complaints, or it can develop gradually, in a relapsing-remiting manner, including, among others, cognitive deterioration and psychiatric illness. The occurrence of Hashimoto encephalopathy is unrelated to the patient's thyroid function status. Although the pathogenesis of this encephalopathy is not fully understood, evidence for both autoimmune and vasculitic mechanisms exists. Owing to a low index of suspicion, this encephalopathy is very likely underdiagnosed in children. The diagnosis of Hashimoto encephalopathy is based on detecting antithyroid antibodies in these patients, although there is no correlation between antibody levels and the severity of the illness. Cerebrospinal fluid analysis, electroencephalography, and neuroimaging studies do not show consistent findings to support the diagnosis. Physicians' awareness of this complication is of great importance because most patients respond dramatically to corticosteroid therapy. Moreover, early recognition might also avoid an expensive diagnostic work-up in patients with unexplained encephalopathy (J Child Neurol 2006;21:1-5).

Hashimoto Encephalopathy with Pegylated Interferon Alfa-2b and Ribavirin

OBJECTIVE:

To report an instance of Hashimoto encephalopathy probably resulting from pegylated interferon alfa-2b and ribavirin.

CASE SUMMARY:

A 36-year-old woman with a 10-year history of autoimmune thyroiditis presented with symptoms and signs consistent with Hashimoto encephalopathy during therapy with pegylated interferon alfa-2b and ribavirin for chronic hepatitis C.

DISCUSSION:

Hashimoto encephalopathy is a rare autoimmune condition that occurs in patients with Hashimoto thyroiditis and high titers of antithyroid antibodies. It is characterized by a variety of nonspecific neuropsychiatric symptoms, increased cerebrospinal fluid protein level, and abnormal brain imaging and electroencephalogram. Prompt response to corticosteroids is observed in most cases. As of August 29, 2005, this is the first report of such an association. An objective causality assessment revealed that the Hashimoto encephalopathy was probably caused by the patient's medications.

CONCLUSIONS:

Hashimoto encephalopathy may rarely be triggered by interferon alfa therapy in susceptible patients.

Adverse psychological effects of corticosteroids in children and adolescents

Children and adolescents treated with oral, inhaled, and intravenous corticosteroids (CS) may experience adverse psychological side effects (APSE), including psychotic symptoms. These can occur at any point during treatment, including withdrawal. In this paper the literature on these effects in children and adults is reviewed. From the evidence available, it is not possible to give reliable estimates for incidence or prevalence of APSE, nor clear risk factors. Some evidence is reported to suggest that oral dexamethasone treatment may carry a higher risk of APSE than other CS, but this requires further investigation. There is evidence from the adult literature that higher CS doses increase the risk of APSE. However, the dose response effect is not straightforward or predictable for individuals or groups. This is likely to be a reflection of the complex effects of CS on the central nervous system and the probable interplay between individual susceptibility, disease factors, and external environmental stressors in the emergence of APSE. More research is required to further our understanding of the adverse effects of these clinically valuable agents.