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BRAIN and NERVE Volume 66, Issue 12 （December 2014）

BRAIN and NERVE 66巻12号（2014年12月発行）

Japanese English

症例報告

脳梗塞加療中に甲状腺クリーゼ，遷延性精神症状を呈した無治療バセドウ病の1例 Prolonged Psychosis Associated with Thyrotoxicosis During the Subacute Stage of Cardioembolic Stroke in a Patient with Untreated Basedow Disease 菊池俊輔 ^1,2 , 緒方利安 ¹ , 深江治郎 ¹ , 津川潤 ¹ , 合馬慎二 ¹ , 田邉真紀人 ² , 柳瀬敏彦 ² , 坪井義夫 ¹ Shunsuke Kikuchi ^1,2 , Toshiyasu Ogata ¹ , Jiro Fukae ¹ , Jun Tsugawa ¹ , Shinji Ouma ¹ , Makito Tanabe ² , Toshihiko Yanase ² , Yoshio Tsuboi ¹ ¹福岡大学医学部神経内科学講座 ²福岡大学医学部内分泌・糖尿病内科学教室 ¹Department of Neurology, Fukuoka University Faculty of Medicine ²Endocrinology, Diabetes and Metabolism, Fukuoka University Faculty of Medicine キーワード：多発脳塞栓 , 心房細動 , バセドウ病 , 甲状腺クリーゼ , 精神症状 , cerebral embolism , atrial fibrillation , Basedow disease , thyroid crisis , psychotic manifestation Keyword: 多発脳塞栓 , 心房細動 , バセドウ病 , 甲状腺クリーゼ , 精神症状 , cerebral embolism , atrial fibrillation , Basedow disease , thyroid crisis , psychotic manifestation pp.1509-1514

発行日 2014年12月1日 Published Date 2014/12/1

DOI https://doi.org/10.11477/mf.1416200066

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症例は57歳女性。無治療のバセドウ病より誘発された心房細動を基礎に，多発心原性脳塞栓を併発し，意識障害と右片麻痺を呈した。抗凝固療法とチアマゾール投与を開始したが，治療中に甲状腺クリーゼを発症し精神症状が増悪した。抗甲状腺薬増量やステロイドなどで加療したが，甲状腺機能正常化後も精神症状はしばらく遷延した。脳梗塞とバセドウ病を合併した患者が甲状腺クリーゼを発症した場合は，精神症状が遷延する可能性があり慎重な治療が必要である。

Abstract

A 57-year-old female developed dizziness and forgetfulness several days before admission. She was admitted to our hospital because of a headache and nausea. On admission, she had a mild disturbance of consciousness and right hemiparesis. Initial MR imaging revealed multiple infarctions in the acute-to-subacute phases in the right cerebellum, left occipital lobe, and bilateral parietal lobes. Her electrocardiogram showed atrial fibrillation and transesophageal echocardiography revealed the presence of a thrombus at the left atrial appendage, suggesting that she suffered from cardioembolic stroke. Laboratory testing showed elevated free T4 levels and low thyroid stimulating hormone (TSH) levels with positive anti-TSH receptor antibodies, indicating untreated Basedow disease. Although treatment with anticoagulants and methimazole was initiated, her postural tremor, tachycardia, and psychosis deteriorated. On the 8^th day of admission, thyrotoxic crisis was confirmed. Despite increased doses of methimazole, as well as treatments with inorganic iodine, steroids, and β-blockers, her psychosis prolonged even after her thyroid function was normalized. Long-term use of antipsychotic medications was required to treat her psychosis. In this case, neurotoxicity of the anti-TSH antibodies related to Basedow disease may have caused prolonged psychosis because of the extensive damage to the blood-brain-barrier function following multiple ischemic strokes. Careful observation and treatment are required for psychotic symptoms, in addition to the treatment for acute stroke in such cases, where thyrotoxic crisis is associated with ischemic stroke.

(Received March 11, 2014; Accepted June 10, 2014; Published December 1, 2014)