Atormac
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 5784  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
  »  Article in PDF (412 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 » Acknowledgments
 »  References
 »  Article Figures

 Article Access Statistics
    Viewed2657    
    Printed99    
    Emailed0    
    PDF Downloaded64    
    Comments [Add]    
    Cited by others 4    

Recommend this journal

 


 
Table of Contents    
LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 2  |  Page : 235-236

Isolated myelopathy probably associated with Hashimoto's disease


Department of Neurology, Saitama Medical University, Saitama, Japan

Date of Submission18-Nov-2011
Date of Decision03-Jan-2012
Date of Acceptance04-Mar-2012
Date of Web Publication19-May-2012

Correspondence Address:
Keisuke Ishizawa
Department of Neurology, Saitama Medical University, Saitama
Japan
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.96418

Rights and Permissions



How to cite this article:
Ishizawa K, Tomioka R, Nakazato Y, Araki N. Isolated myelopathy probably associated with Hashimoto's disease. Neurol India 2012;60:235-6

How to cite this URL:
Ishizawa K, Tomioka R, Nakazato Y, Araki N. Isolated myelopathy probably associated with Hashimoto's disease. Neurol India [serial online] 2012 [cited 2020 Jan 26];60:235-6. Available from: http://www.neurologyindia.com/text.asp?2012/60/2/235/96418

FNx01This case was presented at a conference of Japanese Society of Neurology in September 2010.


Sir,

While encephalopathy is a well-known neurological complication of Hashimoto's disease, [1] myelopathy associated with Hashimoto's disease is rare. [2] This report documents one such case.

A 70-year-old male was admitted for urinary incontinence and difficulty in walking of 1 month duration. He had a past history of spinal canal stenosis. Neurological examination revealed severe paraparesis and sensory disturbance below the umbilicus. Deep tendon reflexes in the lower limbs were exaggerated, but extensor plantar response was not elicited. Magnetic resonance imaging (MRI) of the spine disclosed intramedullary high-intensity signal extending thoracic and lumbar segments on T2-weighted image [Figure 1]a with gadolinium enhancement [Figure 1]c. Brain MRI was normal. Serum-free triiodothyronine (2.71 pg/ml), free thyroxine (1.36 ng/dl), and thyroid stimulating hormone (1.94 μIU/ml) were normal. Anti-thyroid peroxidase antibody (TPOAb) and anti-microsomal antibody by a hemagglutination technique (MCHA) were elevated, 273 IU/ml and x25600, respectively. Thyroid stimulating hormone receptor antibody (TRAb) was normal (0.5 IU/l). ANA, anti-dsDNA, anti-SSA and anti-SSB, anti-HTLV-I, anti-aquaporin 4 antibodies, as well as ACE, and serum vitamin levels were normal or negative. Serum anti-alpha-enolase antibody, which is a marker of Hashimoto's encephalitis [3] was negative. Cerebrospinal fluid (CSF) analysis showed: white blood cells: lymphocytes 11/μl, neutrophils 0/ μl; protein: 228 mg/dl; glucose: 40 mg/dl; TPOAb: 46 IU/ ml; MCHA: ×6400; IgG index: 0.64; oligoclonal band: negative; microorganisms and atypical cells: negative. Neck echography showed diffuse swelling of the thyroid. He was given two cycles of 1 g intravenous methylprednisolone for 3 days with which his symptoms ameliorated. Follow-up MRI showed improvement in the spinal cord signal changes [Figure 1]b and d. After the treatment, TPOAb and MCHA in the serum were 230 IU/ml and ×25600, respectively, and those in the CSF were 11 IU/ml and ×1600, respectively. He remained well for the subsequent 1 year.
Figure 1: The spinal MRI of the patient is shown. Before (a, c) and after (b, d) the treatment; T2-weighted (a, b) and gadolinium-enhanced T1-weighted (c, d) images. (a, c) Before the treatment, the T2-high intensity signal spanned the thoracic and lumbar spinal cord (a), which was well enhanced by gadolinium (c). (b, d) After the treatment, the T2-high intensity signal considerably diminished (b), and the lesion became less enhanced by gadolinium (d). Th, thoracic; T2, T2-weighted MRI; Gd-T1, gadolinium-enhanced T1-weighted MRI

Click here to view


Although the patient was euthyroid, elevated serum TPOAb and MCHA with diffuse swelling of the thyroid and absence of TRAb, suggest the diagnosis of Hashimoto's disease. Both the thyroid antibodies have a high level of sensitivity and specificity for the diagnosis of Hashimoto's disease (sensitivity: 73.5% for TPOAb, 65.1% for MCHA; specificity: 96% for both). [4] With treatment the neurological symptoms and MRI findings improved, and the antibodies decreased in both the CSF and serum. Since the clinical and radiological picture of the patient is nonspecific, we cannot totally exclude etiologies other than Hashimoto's disease. Nonetheless the clinical course of the patient with the laboratory data, suggest a probable diagnosis of myelopathy associated with Hashimoto's disease. Myelopathy associated with Hashimoto's disease is rare. To date, only one report is available. Azuma et al, [2] reported a 70-year-old female with a history of Hashimoto's disease. She felt difficulty in walking, and neurological examination revealed thoracic myelopathy. CSF showed elevated anti-thyroglobulin and antimicrosomal antibodies. She made a good recovery with steroid treatment. During follow-up, she showed features of Hashimoto's encephalopathy, and previously unrecognized T2-high signal intensity in the thoracic spinal cord on MRI. When compared to this patient, our patient did not have Hashimoto's encephalopathy: Brain MRI was normal and the serum anti-alpha-enolase antibody was negative. The anti-alpha-enolase antibody has a high level of sensitivity and specificity for the diagnosis of Hashimoto's encephalopathy (Sensitivity: 51.3%, Specificity: 90.5%; personal communication Dr. A. Matsunaga and Dr. M. Yoneda, University of Fukui, Japan).


 » Acknowledgments Top


The authors thank Dr. A. Matsunaga and Dr. M. Yoneda, the Second Department of Internal Medicine (Neurology), Faculty of Medical Sciences, University of Fukui, Japan, for the analysis of the anti-alpha-enolase antibody and the valuable data regarding this antibody.

 
 » References Top

1.Brain L, Jellinek EH, Ball K. Hashimoto's disease and encephalopathy. Lancet 1966;2:512-4.  Back to cited text no. 1
[PUBMED]    
2.Azuma T, Uemichi T, Funauchi M, Doi S, Matsubara T. Myelopathy associated with Hashimoto's disease. J Neurol Neurosurg Psychiatry 2000;68:681-2.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Yoneda M, Fujii A, Ito A, Yokoyama H, Nakagawa H, Kuriyama M. High prevalence of serum autoantibodies against the amino terminal of alpha-enolase in Hashimoto's encephalopathy. J Neuroimmunol 2007;185:195-200.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Kasagi K, Kousaka T, Higuchi K, Iida Y, Misaki T, Alam MS, et al. Clinical significance of measurements of antithyroid antibodies in the diagnosis of Hashimoto's thyroiditis: comparison with histological findings. Thyroid 1996;6:445-50.  Back to cited text no. 4
[PUBMED]    


    Figures

  [Figure 1]

This article has been cited by
1 Hashimotoæs encephalopathy - presenting with epilepsia partialis continua and a frontal lobe lesion
Lokesh A. Rukmangadachar,Sudeepta Dandapat,Esther N. Bit-Ivan,Yen-Yi Peng
Clinical Case Reports. 2018; 6(1): 136
[Pubmed] | [DOI]
2 NEUROLOGINES SKYDLIAUKES LIGU KOMPLIKACIJOS
Liudmila Kimševaite
Medicinos teorija ir praktika. 2015; 21(4.3): 786
[Pubmed] | [DOI]
3 Myeloneuropathy in a case of hashimotoæs disease
Kayal, A.K., Basumatary, L.J., Dutta, S., Islam, S., Mahanta, A.
Neurology India. 2013; 61(4): 426-428
[Pubmed]
4 Myélopathie d’Hashimoto
M. Billhot-Alinc,A. Vauthier,M. Aletti,C. Jacquier,A. Wemel,J. Robert,A. Vannier,E. Zing,O. Berets
La Revue de Médecine Interne. 2012; 33: A182
[Pubmed] | [DOI]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow