The Third Time's the Charm

Hashimoto's encephalopathy (HE) is an uncommon condition that can present with a rapidly progressive decline and should be considered in patients who present with recurrent mental status changes in the setting of normal imaging studies and routine laboratory results. The entity, in the most recent terminology, is known as steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT). It is characterized by an acute or subacute encephalopathy associated with thyroid autoimmunity. Patients typically present with fluctuating symptoms, episodes of confusion, alterations of consciousness, and rapid cognitive decline. Different approaches to the treatment of HE have been recommended. As the acronym SREAT suggests, patients typically respond dramatically to high-dose steroid therapy.