Background : Hashimoto’s encephalopathy (HE)  also called SREAT ( steroid responsive encephalopathy associated with hypothyroidism) or encephalopathy associated with autoimmune thyroid disease (EAATD) is characterized by persistent or relapsing neurologic and/or neuropsychiatric symptoms associated with raised titers of antithyroid (Anti-Thyroid Peroxidase and Antithyroglobulin) antibodies. The clinical spectrum of HE  is wide and can mimic several other disorders. Tics  are one of the most common movement disorder in children. Tics in association with HE  has been described  previously in children making it a potentially treatable cause.

Case characteristics: We describe a   11 year old adolescent boy who presented with subacute onset of encephalopathy in the form of excessive sleepiness and change in behaviour followed by complex motor and vocal tics. Due to  the presence of associated hypothyroidism, high titer of antithyroid antibodies ( Antithyroglobulin antibody and Anti-Thyroid Peroxidase antibody ), exclusion of other possible etiologies including infectious ,anti- NMDA encephalitis) and therapeutic response to steroids, a diagnosis of HE  was made.He was treated with IV methylprednisolone followed by oral steroids along with thyroxine supplementation . There was complete  resolution of his symptoms. However, his symptoms recurred  on steroid tapering and was added on azathioprine. At followup one year later he is symptom  free with no deficits.

Conclusion : Being a treatable condition,  HE should be suspected in any child presenting with unexplained encephalopathy, cognitive dysfunction, or psychiatric manifestations  including presence of  tics.