Hashimoto’s Encephalopathy After Intensive Lymphocyte Depletion With Rabbit Anti-thymocyte Globulin in a Renal Transplant Patient

Abstract

There has been no reported case of Hashimoto's encephalopathy (HE) ('steroid-responsive encephalopathy associated with autoimmune thyroiditis', 'SREAT'), in the renal transplant recipient population. We describe the case of a 55-year-old female with Type-1 diabetes who presented 2 years posttransplantation in a comatose state that had developed over the preceding 24 h. The patient had received a short, intensive course of rATG induction at the time of transplantation and early steroid withdrawal. After 6 months she had been withdrawn from calcineurin inhibitors and was maintained on mycophenolate mofetil and sirolimus. Systematic workup determined the cause of her coma to be HE. High-dose steroid therapy resulted in complete resolution of the patient's symptoms. The literature regarding the diagnosis, course and treatment of HE is reviewed and the possibility that increased use of steroid-free immunosuppression and intensive lymphocyte depletion regimens may increase the prevalence of de novo autoimmune disease is discussed.

Hashimoto's encephalopathy after interferon therapy for hepatitis C virus in adult liver transplant recipient accompanied by post-transplant lymphoproliferative disorder related to Epstein-Barr virus infection

“…HE is quite rare, and only 1 case in the transplantation field has been reported after intensive lymphocyte depletion in a renal transplant recipient (6). Indeed, HE was not considered in the differential diagnosis at all, until our patient's reaction to SPT.…”

“…Interferon is used frequently for treatment of hepatitis C virus (HCV) infection, and HE after introduction of interferon in a patient with HCV and autoimmune disease has been reported (5). Also, a case of HE after lymphocyte depletion in a renal transplant recipient has been reported (6).…”

Hashimoto Encephalopathy: A Rare Intricate Syndrome

“…Although HE has not been reported in the renal recipient populations, the authors discussed the possibility that the increased use of steroid-free immunosuppression after renal transplantation as well as the intensive lymphocyte depletion regimen possibly increased the opportunity for de novo autoimmune disease onset (45). Lithium-induced HE in a 61-year-old woman with a type II bipolar disorder has been also reported.…”

A patient with steroid responsive encephalopathy associated with autoimmune thyroiditis

“…This is particularly important because neurosarcoidosis has a poor prognosis and aggressive immunosuppressive treatment is generally recommended. 1 We present a man with clinically suspected neurosarcoidosis where attempts to obtain histological confirmation of disease through skin and meningeal biopsy was unhelpful but lymph node biopsy, directed with the use of [18F]-fluorodeoxyglucose (FDG)-positron emission tomography/CT (FDG-PET/CT) scanning, was diagnostic.…”

“…1 In neurosarcoidosis the central nervous system (CNS) is often the only affected site making a tissue diagnosis difficult. 1 Whilst a clinical diagnosis of neurosarcoidosis can often be made, 2 the wide range of potential differential diagnoses, including other steroid responsive conditions (such as idiopathic lymphocytic meningitis) means a confirmed diagnosis is invaluable. This is particularly important because neurosarcoidosis has a poor prognosis and aggressive immunosuppressive treatment is generally recommended.…”