Acute encephalopathy as an initial manifestation of pediatric Graves’ disease

Abstract

  Thyroid storm is characterized by multiple organ failure due to thyrotoxicosis, and may be associated with neurological manifestations such as psychosis, agitation, confusion, and even seizures. Acute encephalopathy is a very rare complication of thyroid storm in children. We describe a child patient presenting with acute encephalopathy associated with thyroid storm due to Graves’ disease. A seven-year-old girl presented having noticed fatigue and headaches. She could not use a spoon well with her right hand. Neurological examination revealed fluctuating drowsiness, finger agnosia, left-right disorientation, rigid position and poor function of the right hand ; the patient subsequently developed right hemiplegia, aphasia, and hemi-convulsions. Electroencephalography revealed slow waves in the left frontal area. The patient was diagnosed with acute encephalopathy due to Graves’ disease with high levels of thyroid hormones and suppressed thyroid stimulating hormone. Thyroid antibodies were strongly positive. Magnetic resonance imaging showed cortical vasogenic edema in the left cerebral hemisphere, and vascular enhancement in the left cerebral hemisphere surface. Magnetic resonance angiography showed prominent left peripheral middle and posterior cerebral arteries. The patient was administered high-dose methylprednisolone, thiamazole and Lugol’s iodine solution ; subsequently, the patient’s consciousness, motor ability and aphasia gradually improved. We suspect that the patient’s neurological manifestations were due to cerebral hyperperfusion and vasogenic cortical edema due to the thyrotoxicosis. We suggest that regional cerebral involvement may occur as a complication of thyrotoxicosis. Thyroid storm should be considered as a possible cause of regional acute encephalopathy.