Assessment and Management of Acute Disseminated Encephalomyelitis (ADEM) in the Pediatric Patient

Bacterial and Viral Infectious Disease of the Spine

Spinal infections are a diverse group of diseases affecting different compartments of the spine with variable clinical and imaging presentations. Diagnosis of spinal infections is based on a combination of clinical features, laboratory markers, and imaging studies. Imaging plays a pivotal role in the diagnosis and management of spinal infections. The characteristic imaging manifestations of bacterial and viral infections in the spine are discussed with key teaching points emphasized.

Role of physical therapy intervention in acute disseminated encephalomyelitis

We reported a case of a school-going child, diagnosed with acute disseminated encephalomyelitis (ADEM) who presented with symptoms such as high fever, acute hemiplegia and ataxia and was referred for physiotherapeutic intervention. This case report aims to document the assessment and management of ADEM from the intensive care unit to the home setting by physical therapy. Also, the child developed ventilator-associated pneumonia and a right lower motor neuron facial injury for which the child was referred to paediatric physical therapy. Since then, continuing for 8 months has helped the child to be independent in all aspects of mobility with no complaints. The child showed improvement in WeeFIM scores and Sunnybrook facial grading after 99 sessions of intensive physical therapy for approximately 83 hours along with the home programme. It has been proven an efficient treatment method along with other medical lines of treatment for neurological impairment associated with ADEM.

Acquired Demyelinating Syndromes

Acquired demyelinating syndromes (ADS) are a heterogenous group of inflammatory demyelinating conditions that include presentations of optic neuritis, transverse myelitis, and acute demyelinating encephalomyelitis. They can be monophasic or can develop into relapsing episodes of the initial demyelinating event or evolve to include other types of demyelination. Significant progress has been made in differentiating subtypes of ADS that differ in their tendency to relapse and in which anti-inflammatory therapies are effective. Differentiating between these subtypes is important for the optimal management of these patients. Clinical features, labs (especially autoantibodies), and MRI findings can help to differentiate between the different ADS.

Acute disseminated encephalomyelitis and viral encephalitis: An unusual and misleading imaging

Acute disseminated encephalomyelitis (ADEM) is a rare illness. It is characterized by different presentations like encephalopathy, seizures, hemiplegia, and visual symptoms. We present a patient who presented seizures and encephalopathy. Brain MRI showed symmetrical white and gray matter lesions. He was treated with acyclovir for viral encephalitis and given immunotherapy for ADEM. The radiological findings may be inconclusive in some cases, hence differential diagnosis of both viral encephalitis and ADEM needs to be considered. Early immunotherapy is required in such fulminant cases.

Acute Disseminated Encephalomyelitis in a Six-Year-Old Child: A Case Report

Acute disseminated encephalomyelitis (ADEM) is a rare autoimmune demyelinating disorder that primarily affects the central nervous system (CNS). It is characterized by an acute inflammatory response targeting the myelin sheath surrounding nerve fibers in the brain and spinal cord. The exact mechanism of ADEM is not fully understood, but it is believed to involve an abnormal immune response that leads to the activation of immune cells and subsequent inflammation within the CNS. This immune-mediated attack results in the destruction of myelin, impairing the transmission of nerve signals and causing a wide range of neurological symptoms. This is a case of a six-year-old girl with no notable medical history presented with complaints of a fever and headache for the last month, in addition to difficulty walking for 20 days and speaking for 14 days. On CNS examination, the right upper and lower limbs' power was reduced, and the Babinski sign was seen in both lower limbs. Both sides of the triceps and knee showed increased reflexes, whereas both sides of the ankle showed decreased reflexes. Magnetic resonance imaging (MRI) showed multiple T1 hypointensities and T2-weighted fluid-attenuated inversion recovery (T2-FLAIR) hyperintensities in the subcortical white matter of the bilateral frontal and parietal lobes, bilateral cerebellar peduncles, corpus callosum, pons, and midbrain. Our case report aims to raise awareness and aid in the early recognition of ADEM because prompt recognition, accurate diagnosis, and appropriate management are essential to minimizing neurological damage and promoting favorable outcomes in affected individuals.

Myelin Oligodendrocyte Glycoprotein (MOG) Associated Diseases: Updates in Pediatric Practice

Myelin oligodendrocyte glycoprotein (MOG) is a membrane bound protein found on the surface of oligodendrocyte cells and the outermost surface of myelin sheaths. MOG is posited to play a role as a cell surface receptor or cell adhesion molecule, though there is no definitive answer to its exact function at this time. In the last few decades, there has been a recognition of anti-MOG-antibodies (MOG-Abs) in association with a variety of neurologic conditions, though primarily demyelinating and white matter disorders. In addition, MOG associated disease (MOGAD) appears to have a predilection for pediatric populations and in some patients may have a relapsing course. There has been considerable debate as to whether MOG-Abs are truly directly pathogenic or a disease biomarker associated with neuorinflammatory disease. In this manuscript we will review the current literature surrounding MOGAD, review new clinical phenotypes, discuss treatment and prognosis, and provide insight into potential future directions that studies may focus on.

An Adult Case of Adenovirus-Associated Acute Disseminated Encephalomyelitis

Acute disseminated encephalomyelitis (ADEM) is an autoimmune neurological disease that predominately affects pediatric population. Only a single fatal adult case of adenovirus-associated ADEM has previously been published by Qamar et al. in 2021. Here, we present an adult case of adenovirus-associated ADEM, which was diagnosed early in her clinical course. The patient was treated with the prompt initiation of steroids, intravenous immune globulin (IVIG), and plasmapheresis (PLEX), and the patient recovered fully. This case highlights the importance of early accurate diagnosis for other clinicians to treat adenovirus-associated ADEM in a timely fashion to prevent a potentially fatal outcome.

The immunomodulatory roles of the gut microbiome in autoimmune diseases of the central nervous system: Multiple sclerosis as a model

The gut-associated lymphoid tissue is a primary activation site for immune responses to infection and immunomodulation. Experimental evidence using animal disease models suggests that specific gut microbes significantly regulate inflammation and immunoregulatory pathways. Furthermore, recent clinical findings indicate that gut microbes' composition, collectively named gut microbiota, is altered under disease state. This review focuses on the functional mechanisms by which gut microbes promote immunomodulatory responses that could be relevant in balancing inflammation associated with autoimmunity in the central nervous system. We also propose therapeutic interventions that target the composition of the gut microbiota as immunomodulatory mechanisms to control neuroinflammation.

Acute Disseminated Encephalomyelitis Following COVID-19 Infection

Acute disseminated encephalomyelitis (ADEM) is a relatively rare, post-inflammatory, immune-mediated demyelinating central nervous system disease that is predominantly reported in pediatric populations. Following the emergence of severe acute respiratory syndrome coronavirus 2, cases of ADEM are being reported following infection with this virus. Our case report describes a male patient in his early 40s who developed severe coronavirus disease 2019 (COVID-19) that rapidly progressed to a critical disease requiring invasive mechanical ventilation and high positive end-expiratory pressure, which was complicated by extensive neurological involvement and quadriplegia. MRI of the brain showed characteristic demyelinating lesions, suggestive of ADEM. As other entities were ruled out, our patient was treated using pulse steroids and intravenous immunoglobulins. The patient showed a good response to treatment and had an overall good prognosis, despite the severity of his condition. ADEM following COVID-19 is a rare entity worldwide.

Two-year follow-up of a young male with possible acute hemorrhagic leukoencephalitis: A case report

RATIONALE

Acute hemorrhagic leukoencephalitis (AHLE) is a rare but fetal fulminant demyelinating disease of unknown etiology. It is commonly regarded as a severe variant of acute demyelinating encephalomyelitis (ADEM). Its rapid clinical deterioration and high mortality appeal to clinicians to attach importance to early diagnosis. Immunosuppressive therapy is the main management to attenuate the autoimmune process, but with varied response and prognosis.

PATIENT CONCERNS

A young male presented with moderate fever, headache and seizures after extraction of impacted teeth, and then deteriorated rapidly to deep coma. Initial magnetic resonance imaging (MRI) revealed multiple plaque-like lesions in bilateral cerebra, right thalamus and pontobulbar region with massive edematous swelling and multifocal small hemorrhagic foci. Inflammatory parameters in the peripheral blood were only mild higher with a pleocytosis in CSF.

DIAGNOSIS

His clinical presentation, laboratory evaluation and radiological features were consistent with a suspected diagnosis of AHLE.

INTERVENTIONS

He underwent pulse corticosteroids initially but failed to respond to it. However, his consciousness improved obviously when he was treated with multiple courses of intravenous injection of immunoglobulin (IVIG) combined with mycophenolate mofetil (MMF).

OUTCOMES

The patient regained consciousness gradually on day 180 and was in minimally conscious state (MCS) during the two-year follow-up.

LESSONS

AHLE presents distinctly from classical ADEM, and the situation may pose a diagnostic challenge. Clinicians should be vigilant in recognizing AHLE because of its rapid clinical deterioration and high mortality. We highlight the critical role of multimodal MRI, particularly susceptibility-weighted imaging (SWI) in the diagnosis of AHLE if cerebral biopsies are unavailable. Multiple courses of IVIG with MMF may be effective when early single pulse of corticosteroids fails. Individual who survives the initial insult may carry relatively good prognosis.

Leptospira infection complicated by demyelinating disease: A case report

Leptospirosis is a zoonotic disease, found worldwide, that is caused by bacteria of the genus Leptospira. People can be infected with Leptospira if they come in direct contact with the urine of an infected animal. Leptospirosis may be associated with demyelinating lesions of the central nervous system. This case report describes a 66-year-old female patient who presented with fever and generalized aches and progressed to unconsciousness within a few hours of admission. Laboratory tests showed Leptospira infection, and brain magnetic resonance imaging revealed acute demyelinating lesions. The patient responded well to penicillin and intravenous methylprednisolone therapy. Leptospirosis presenting with acute disseminated encephalomyelitis is rare. In this patient, an interdisciplinary collaboration involving the neurologist, radiologist, and pathologist was crucial for diagnosis and management. Further studies are warranted to investigate whether there is a correlation between demyelinating lesions and leptospiral infection.

Clinical characteristics and associated factors of pediatric acute disseminated encephalomyelitis patients with MOG antibodies: a retrospective study in Hangzhou, China

Background

To explore the clinical characteristics and related factors of children with acute disseminated encephalomyelitis (ADEM) with positive anti-myelin oligodendrocyte glycoprotein (MOG) antibody.

Methods

A retrospective study was conducted and enrolled pediatric ADEM patients who underwent serum MOG antibody detection from May 2017 to August 2020. The patients were divided into two groups: MOG- immunoglobulin G (IgG) positive (n = 35) and MOG-IgG negative (n = 50). We analyzed the clinical characteristics of MOG-IgG-positive ADEM pediatric patients and conducted a comparative analysis between the two groups.

Results

Thirty-five patients (21 males and 14 females) in the MOG-IgG-positive group with encephalopathy, multifocal neurological symptoms, and typical magnetic resonance imaging (MRI) abnormalities were enrolled. They usually had a favorable outcome, while some suffered from relapse. Compared to the MOG-IgG-negative group, MOG-IgG-positive ADEM patients had a longer disease duration (median: 10 vs. 6 days), more meningeal involvement (31.4% vs. 8%) and frontal lobe involvement (82.8% vs. 68%), higher relapse rates (14.3% vs. 2%), lower serum tumor necrosis factor (1–12.4 pg/ml, median 1.7 vs. 1–34 pg/ml, median 2.2) and interferon-gamma (1–9.4 pg/ml, median 1.3 vs. 1–64 pg/ml, median 3) (P < 0.05, respectively). Multivariate logistic regression analysis showed that the longer disease duration, meningeal involvement and frontal lobe involvement were the correlated factors of patients with ADEM with MOG antibody (P < 0.05).

Conclusions

Our findings provide clinical evidence that MOG-IgG positivity is associated with longer disease duration, meningeal involvement, and frontal lobe involvement.

Juvenile Idiopathic Arthritis, Uveitis and Multiple Sclerosis: Description of Two Patients and Literature Review

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in childhood, while multiple sclerosis (MS) is a demyelinating disease of the central nervous system, characterized by remission and exacerbation phases. An association between MS and rheumatologic diseases, in particular rheumatoid arthritis, has been described and numerous studies acknowledge anti-TNF-α drugs as MS triggers. Conversely, the association between MS and JIA has been reported merely in five cases in the literature. We describe two cases of adult patients with longstanding JIA and JIA-associated uveitis, who developed MS. The first patient was on methotrexate and adalimumab when she developed dizziness and nausea. Characteristic MRI lesions and oligoclonal bands in cerebrospinal fluid led to MS diagnosis. Adalimumab was discontinued, and she was treated with three pulses of intravenous methylprednisolone. After a few months, rituximab was started. The second patient had been treated with anti-TNF-α and then switched to abatacept. She complained of unilateral arm and facial paraesthesias; brain MRI showed characteristic lesions, and MS was diagnosed. Three pulses of intravenous methylprednisolone were administered; neurological disease remained stable, and abatacept was reintroduced. Further studies are warranted to define if there is an association between JIA and MS, if MS represents JIA comorbidity or if anti-TNF-α underpins MS development.

Shigella-associated mild encephalitis with reversible splenial lesion in Hospital Center Delafontaine, Saint-Denis, France: a case report

BACKGROUND

Mild encephalitis with reversible splenial lesion of the corpus callosum (MERS) is a clinical/radiological syndrome characterized by hyperintense signal changes in the splenium of the corpus callosum visible on diffusion weighted imaging (DWI) in the brain Magnetic Resonance Imaging (MRI) associated with various neurological symptoms. Progression is usually favorable with disappearance of the MRI brain lesion and regression of clinical symptoms over a few days to a few weeks. The exact pathophysiology remains unclear. MERS can be associated with various pathogens.

CASE PRESENTATION

We report here a paediatric case of MERS associated with Shigella flexneri infection. A five-year-old boy with no relevant past medical history presented with symptoms such as headache, fever, profuse diarrhea and hallucinations. A brain Magnetic Resonance Imaging performed on Day 2 of the symptoms revealed hyperintense signal changes of the splenium of the corpus callosum in T2 FLAIR sequence. This infection had a favorable outcome after antibiotic therapy. No further recurrence of symptoms was observed and a follow-up clinical examination eight weeks later was normal. A follow-up brain Magnetic Resonance Imaging three months after discharge was also normal and the hyperintense signal changes of the splenium of the corpus callosum had disappeared completely.

CONCLUSIONS

MERS is a clinical/radiological syndrome with a generally good prognosis. We believe that this is the first description of a case of Shigella-associated MERS. It is useful to know about this condition to help distinguish it from acute disseminated encephalomyelitis.

An Atypical Presentation of West Nile Virus With Successful Treatment After Plasma Exchange and Intravenous Immunoglobulin

West Nile (WN) disease is a relatively rare arboviral virus. Neuroinvasive cases of WN account for less than 1% of the total cases. The case described had difficult symptomatology and radical presentation, which included ascending paralysis. To date, there have been very few reports of West Nile cases that present with ascending paralysis. We describe the case of a 63-year-old white male who presented with a fever and proximal muscle weakness in the thighs and legs that rapidly worsened and ascended, eventually resulting in diaphragmatic paralysis. He was intubated after respiratory failure and given intravenous immunoglobulin and plasma exchange. The patient remained ventilated with persistent weakness. However, this improved after intravenous immunoglobulin and plasma exchange therapy. This case serves as a reminder to keep the diagnosis of WN on the differential, a primer on advanced treatments in the setting of aggressive atypical WN, and a lesson on similarly presenting diseases and distinguishing characteristics that may help rule out these diseases from WN.

SARS-CoV-2-associated acute disseminated encephalomyelitis: a systematic review of the literature

The literature on cases of acute disseminated encephalomyelitis (ADEM) associated with SARS-CoV-2 infection has been rapidly increasing. However, the specific clinical features of ADEM associated with SARS-CoV-2 (SARS-CoV-2-ADEM) have not been previously evaluated. We screened all articles resulting from a search of PubMed and Web of Science databases looking for reports of ADEM published between December 01, 2019, and June 5, 2021. Of the 48 ADEM cases identified from 37 studies, 34 (71%) had ADEM while 14 (29%) were of AHLE. RT-PCR for SARS-CoV-2 was positive in 83% (n = 19) of patients. 26 patients (54%) were male, and 18 patients (38%) were female, with a male to female sex ratio of 1.4:1; median age was 44 (1.4–71) years. 9 patients (19%, 9/48) were children. Of the 9 children patients, their median age was 9 years (range 1.4–13 years), 6 patients (67%) were female, and 2 patients (22%) were male, with a female to male sex ratio of 3:1.39 patients (81%) was performed CSF analysis. PCR for SARS-CoV-2 tested positive in 3 patients (14%, 3/22) on CSF sample. 31 (64%) of patients had a poor outcome on discharge from hospital. Five (10%) patients died in hospital. Compared to classic ADEM, SARS-CoV-2-ADEM have a more longer duration between the onset of the antecedent infective symptoms and the start of ADEM symptoms, the older age distribution of the patients, relatively poor outcome, a lower full recovery rate, a more frequently brain lesions involved the periventricular white matter and corpus callosum, and less frequently affected the deep gray matter. Taken together, the present comprehensive review reveals that although rare, ADEM can be associated with SARS-CoV-2 infection. SARS-CoV-2-ADEM seems to share most features of classic ADEM, with moderate discrepancies from the classical ADEM.