Recurrent disseminated encephalomyelitis: A case report and literature review

Rare and Atypical Presentations of Acute Disseminated Encephalomyelitis in Children: A Case Series

Acute disseminated encephalomyelitis (ADEM) is a monophasic demyelinating disorder of central nervous system occurring in children with a wide range of clinical manifestations after infection or vaccination. There are few case reports in literature, describing atypical presentations of ADEM with fever of unknown origin, autonomic dysfunction, complex movement disorders such as myoclonus, dystonia and chorea, acute psychosis and myocarditis. Here, we report four cases of ADEM with atypical features like uniocular blindness, myelin oligodendrocyte glycoprotein antibodies negative multiphasic disseminated encephalomyelitis, ADEM mimicking Guillain-Barre syndrome at presentation and isolated spinal ADEM. Treatment with high-dose steroids elicited an excellent neurological outcome in all patients. A high index of clinical suspicion along-with awareness of atypical features, magnetic resonance imaging and cerebrospinal fluid studies are of paramount importance in establishing ADEM diagnosis and initiation of early treatment for better outcome.

Epidemiology of neurologic disease in pregnancy

Many neurologic diseases in women are influenced by the physiologic and hormonal changes of pregnancy, and pregnancy itself poses challenges in both treatment and evaluation of these conditions. Some diseases, such as epilepsy and multiple sclerosis, have a high enough prevalence in the young female population to support robust epidemiologic data while many other neurologic diseases, such as specific myopathies and muscular dystrophies, have a low prevalence, with data limited to case reports and small case series. This chapter features epidemiologic information regarding a breadth of neurologic conditions, including stroke, epilepsy, demyelinating disease, peripheral neuropathies, migraine, sleep-disordered breathing, and meningioma, in women in the preconception, pregnancy, and postpartum stages.

A unique case of multiphasic ADEM or what else?

BACKGROUND

Acute disseminated encephalomyelitis (ADEM) is a monophasic post-infectious demyelinating disease, clinically defined by the acute onset of polyfocal neurological deficits including encephalopathy. A subset of ADEM patients will subsequently be diagnosed with relapsing disorders, including recurrent DEM (RDEM), multiphasic DEM (MDEM), neuromyelitis optica spectrum disorders (NMOSD) and multiple sclerosis (MS). Here we describe the case of an adult patient, who presented two ADEM-like episodes after a very long (8 years) symptoms-free period.

CLINICAL CASE

A 48 years old man presented a first case of sub-acute onset of encephalopathy and dysarthria with MRI findings suggestive for ADEM for which he underwent an intravenous and oral steroid treatment followed by a complete clinical remission. After 8 years he presented a new sub-acute onset of encephalopathy and balance disorders with the onset of new lesions at the MRI. The search for oligoclonal band (OCB) showed a single CSF-restricted IgG band. Suspecting a new ADEM episode he was treated with intravenous steroids without benefit and 3 apheresis sessions with clinical improvement followed by an oral steroid treatment. After 2 months he experienced a paroxysmal episode of dysarthria, upper and lower left limbs impairment and urge incontinence with a stable new brain and spinal cord MRI. The search for anti-aquaporin-4 and anti-MOG (cell-based assay) antibodies was repeated twice within a 6 months span and resulted in both cases negative. The patient was treated with Rituximab (1g followed by 1g after 15 days, followed by 1g after 6 months) with stability of the neurological and radiological examinations at the last follow-up.

CONCLUSIONS

To the best of our knowledge, this is the first case of MDEM in which the two episodes of ADEM occurred 8 years apart. Although this case fulfills the diagnostic criteria for MDEM, the time elapsed between the two episodes is very long. Therefore, we cannot exclude that this disease might be a new nosological entity that could be included in the expanding range of demyelinating diseases.