Post-COVID-19 acute disseminated encephalomyelitis: Case report and review of the literature

Neurological complications of influenza vaccination: navigating the spectrum with a focus on acute disseminated encephalomyelitis (ADEM)

Introduction

Acute disseminated encephalomyelitis (ADEM) is a rare neurological disorder characterized by inflammation in the brain and spinal cord. This systematic review aims to investigate the potential association between ADEM and influenza vaccination by analyzing relevant case reports. ADEM is traditionally thought to be a monophasic condition, predominantly affecting children, often following viral illnesses or immunizations. Recent attention has focused on a possible link between ADEM and influenza vaccination, prompting the need for a thorough investigation.

Methods

The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the AMSTAR2 (A MeaSurement Tool to Assess systematic Reviews 2) guidelines. Electronic searches were conducted on PubMed, Cochrane Library, and clinicaltrials.gov databases, spanning up to August 2023. Inclusion criteria encompassed full-text articles in English, observational studies, case reports, and case series providing comprehensive details for confirming clinical diagnoses of ADEM following influenza vaccination. Data were extracted, including demographic information, vaccination details, clinical symptoms, diagnostic evaluations, treatment modalities, and outcomes. Quality assessment was performed using the Joanna Briggs Institute (JBI) Critical Appraisal tool.

Results

A total of 23 cases of ADEM following influenza vaccination were identified from 19 included articles. The mean age of affected individuals was 40.2 years (±25.7) with 60.8% being male. Common presenting symptoms included muscle weakness (52.1%), urinary abnormalities (30.4%), altered consciousness (26%), and sensory disturbances (26%). Neurological examination revealed findings such as extensor plantar reflex (positive Babinski sign) in 26%, hyperreflexia in 30.4%, and generalized hyporeflexia in 13% of the cases. Diagnostic evaluations involved MRI, showing multiple hyperintense lesions in cerebral hemispheres (43.4%), subcortex (60.8%), and spinal cord (39.1%). Cerebrospinal fluid analysis indicated elevated white blood cell count in 69.5% of cases, with lymphocytic pleocytosis in 52.1%. Oligoclonal bands were reported positively in 8.6% of cases. Treatment approaches varied, with intravenous methylprednisolone being the most common (39.1%). Out of the 23 cases, two (8.6%) patients had a fatal outcome, while the rest showed clinical improvement with complete or partial resolution of symptoms. Persisting symptoms included numbness in the lower extremities (8.6%) and impaired ability to walk after 10 months (4.3%).

Conclusion

While the association between ADEM and influenza vaccination is rare, healthcare professionals should remain vigilant and consider patients' vaccination history, particularly following an influenza immunization. This systematic review highlights the clinical manifestations, diagnostic tools, treatment approaches, and outcomes of ADEM cases post-influenza vaccination. Further research is essential to understand this association and improve clinical decision-making, ensuring the safety and efficacy of immunization programs.

Acute disseminated encephalomyelitis (ADEM) following COVID-19 vaccination: A systematic review

BACKGROUND

Although global vaccination against COVID-19 infection has its excellence, potential side effects are yet of concern. Several lines of evidence have proposed ADEM occurrence after SARS-CoV-2 infection. Moreover, a large number of case reports and case series have also suggested the casual association between ADEM and COVID-19 vaccination. To better understand the development of ADEM following COVID-19 vaccination and its potential association, we aimed to systematically review ADEM cases reported after COVID-19 vaccination.

METHODS

We conducted a comprehensive systematic search using three databases including PubMed, Scopus, and Web of Science. Studies that reported ADEM after COVID-19 vaccination were eligible to include in our study. Observational studies, case reports, and case series which reported cases of ADEM with sufficient detail to confirm clinical diagnosis following COVID-19 vaccination were eligible to enter our study.

RESULTS

Twenty studies were included in our systematic review after the abstract and full-text screening with a total of 54 cases. Among included patients, 45 (85.1 %) developed ADEM after the first dose of the COVID-19 vaccine, and seven (12.9 %) cases experienced ADEM after the second dose. The median time interval between vaccination and neurological symptoms was 14 days which ranged from 12 h to 63 days. Twelve (22.2 %) patients experienced symptoms of muscle weakness, ten (18.5 %) presented unconsciousness, nine (16.6 %) patients had urinary complaints, nine (16.6 %) had visual impairments, and five (9.2 %) experienced a seizure. After treatments, four (13.8 %) patients died. Forty-six patients had clinical improvement (85.1 %), also improvement in brain MRI was observed among 44 (81.4 %) patients.

CONCLUSION

In conclusion, it is not clear that ADEM could be a potential complication of COVID-19 vaccination based on the current evidence and further studies are needed. However, this rare condition should not trigger stopping the mass vaccination programs since the only way to eradicate the current pandemic of COVID-19 is to extend the number of immunized people.

[Viral diseases of the nervous system-Selected new and old viruses]

Viral diseases of the nervous system are ancient and poliomyelitis was described in Egypt as early as 2000 BC. They can cause a wide range of neurological symptoms, such as meningitis, encephalitis, meningoencephalitis, Guillain-Barré-like syndrome and stroke, often leaving mild to severe residuals. Depending on the pathogen, the symptoms appear quickly within hours, or lead to increasing chronic symptoms within 1 week or months. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was newly identified in January 2020 and occurs worldwide, illustrates the sequelae of a phenomenon that has been known for centuries, the possible rapid spread of pathogen-related infectious diseases. Due to vaccination programs some pathogens are becoming rarer or are considered to be eradicated. Nevertheless, vaccination programs, especially in the poorer regions, are repeatedly interrupted, for example by wars. The most recent example is the interruption of vaccination against poliomyelitis in Ukraine. As life expectancy continues to rise and years of life lost to infectious diseases decrease, the new infectious disease threat is likely to come from emerging and re-emerging infections; however, according to a recent analysis of population data from 29 countries, life expectancy during the corona pandemic has decreased, e.g., by 28 months in the USA and by 6 months in Germany. Climate change, rapid urbanization and changing land-use patterns could increase the risk in the coming decades. In particular, the climate change can alter the spectrum of global pathogens and especially vector-borne infections can spread to new areas. A sustained increase in travel, trade and mobility enables the pathogens to spread quickly.

Acute disseminated encephalomyelitis (ADEM)-like illness in a pediatric patient following COVID-19 vaccination

Since the inception of the COVID-19 pandemic, over 60 cases of ADEM or ADEM-like clinically isolated syndromes have been linked to COVID-19 infection. However, cases linked to COVID-19 vaccination remain exceptionally rare. To the author’s knowledge, eight published cases of ADEM or ADEM-like clinically isolated syndrome have been described after patients received COVID-19 vaccinations, all of which occurred in adults.

This report details the first documented case of an acute disseminated encephalomyelitis (ADEM)-like illness in a pediatric patient, which developed shortly after receiving the Pfizer (Pfizer-BioNTech, Germany) COVID-19 vaccination. The patient made a near complete clinical recovery over 10 days after receiving a 5 day course of intravenous immunoglobulin (IVIG) therapy.

The Wide Variety of Acute Disseminated Encephalomyelitis in Children: A Clinical Perspective

Acute disseminated encephalomyelitis (ADEM) is an acute demyelinating inflammatory disorder of the central nervous system. It is characterized by encephalopathy, multifocal neurological deficits, and typical magnetic resonance imaging findings of widespread demyelinating lesions, predominantly involving the white matter of the brain and spinal cord. ADEM mainly affects children and is commonly associated with preceding viral and bacterial infections, and, rarely, vaccinations. Despite substantial advances in the understanding of the association of myelin oligodendrocyte glycoprotein antibody with recurrent forms of ADEM or other demyelinating conditions, specific etiologic agents or biological markers have not been identified. Therefore, the diagnosis of ADEM is still based on clinical and radiological findings and the exclusion of other conditions mimicking ADEM. However, a prompt diagnosis and adequate treatment are crucial because diagnostic delays or inappropriate treatment may lead to unwanted neurological sequelae in some children. There is no standardized treatment protocol for ADEM, but the use of corticosteroids, intravenous immunoglobulin, and plasmapheresis has been associated with good clinical outcomes. Adequate treatment has reportedly resulted in favorable outcomes, with full or almost full recovery in most children with ADEM, although some children may develop neurological sequelae, such as cognitive impairment and motor deficits. Further studies are needed to identify biological clues and optimal treatment protocols to minimize the incidence of neurological sequelae.