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Abstract
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.
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Affiliation(s)
- Dominic O Co
- Division of Allergy, Immunology, Rheumatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Clinical Science Center (CSC), H6/572, 600 Highland Avenue, Madison, WI 53792, USA.
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Chen LW, Cheng JF, Chang TM, Hsu MH, Huang CC, Chang YC. Prognostic factors for functional recovery in children with moderate to severe acute disseminated encephalomyelitis. Mult Scler Relat Disord 2022; 66:104056. [PMID: 35878513 DOI: 10.1016/j.msard.2022.104056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/25/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute disseminated encephalomyelitis (ADEM) is an immune-mediated encephalopathy with heterogeneous disease courses. However, clinical characteristics for a prognostication of functional recovery from acute episodes of ADEM remain limited. The study aims to characterize the clinical presentations and neuroimaging findings of children with poor functional recoveries from acute episodes of moderate to severe ADEM. METHODS The multicenter retrospective cohort study included children under 18 years of age who presented with moderate to severe ADEM (modified Rankin Scale [mRS] ≥ 3 at nadir) from 2002 to 2019. Children were assigned to a good recovery group (mRS ≤ 2) and a poor recovery group (mRS ≥ 3) after mean 4.3 months of follow-up. The clinical presentations and the distribution of brain lesions on magnetic resonance imaging were compared between the two groups by the t-test for numerical variables and Fisher's exact test for categorical variables. Analyses of logistic regression were conducted and significant variables in the multivariate model were examined by the receiver operating characteristic curve for the prediction of functional recovery. RESULTS Among the 73 children with moderate to severe ADEM, 56 (77%) had good functional recoveries and 17 (23%) showed poor functional recoveries. Children with poor recoveries had a lower rate of prodromal headache (12% vs. 39%, p = 0.04), and presented with higher proportions of dystonia (29% vs. 9%, p = 0.046), myoclonus (24% vs. 2%, p = 0.009), and cerebellar lesions on neuroimages (59% vs. 23%, p = 0.01). The multivariate analyses identified that a lack of prodromal headache (OR 0.1, 95% CI 0.005 - 0.7, p = 0.06) and the presentations of myoclonus (OR 21.6, 95% CI 1.7 - 874, p = 0.04) and cerebellar lesions (OR 4.8, 95% CI 1.3 - 19.9, p = 0.02) were associated with poor functional recoveries. These three factors could prognosticate poor outcomes in children with moderate to severe ADEM (area under the receiver operating characteristic curve 0.80, 95% CI 0.68 - 0.93, p = 0.0002). CONCLUSION Nearly one-fourth of children with moderate to severe ADEM had a poor functional recovery from acute episodes, who were characterized by a lack of prodromal headache, the presentation of myoclonus, and the neuroimaging finding of cerebellar lesions. The clinical variables associated with poor functional recoveries could assist in the planning of immunotherapies during hospitalization for a better outcome in moderate to severe ADEM.
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Affiliation(s)
- Li-Wen Chen
- Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, North District, Tainan, Taiwan
| | - Ju-Fang Cheng
- Department of Pediatrics, Changhua Christian Children's Hospital, 320 Xuguang Road, Changhua City, Changhua County, Taiwan
| | - Tung-Ming Chang
- Department of Pediatrics, Changhua Christian Children's Hospital, 320 Xuguang Road, Changhua City, Changhua County, Taiwan; Department of Biological Science and Technology, College of Biological Science and Technology, National Yang Ming Chiao Tung University, 1001 Daxue Road, East District, Hsinchu, Taiwan
| | - Mei-Hsin Hsu
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Dapi Road, Niaosong District, Kaohsiung City 833, Taiwan
| | - Chao-Ching Huang
- Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, North District, Tainan, Taiwan; Department of Pediatrics, College of Medicine, Taipei Medical University, 50 Wu-Hsing Street, Taipei, Taiwan
| | - Ying-Chao Chang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Dapi Road, Niaosong District, Kaohsiung City 833, Taiwan.
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Finsterer J, Scorza FA. Neuro-COVID Requires Comprehensive Work-up. Indian J Crit Care Med 2021; 25:956-957. [PMID: 34733045 PMCID: PMC8559751 DOI: 10.5005/jp-journals-10071-23926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Finsterer J, Scorza FA. Neuro-COVID Requires Comprehensive Work-up. Indian J Crit Care Med 2021;25(8):956-957.
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Affiliation(s)
| | - Fulvio A Scorza
- Neuroscience Discipline, Escola Paulista de Medicina/Universidade Federal de São Paulo/(EPM/UNIFESP), São Paulo, Brazil
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Netravathi M, Holla VV, Nalini A, Yadav R, Vengalil S, Oommen AT, Reshma SS, Kamble N, Thomas PT, Maya B, Pal PK, Mahadevan A. Myelin oligodendrocyte glycoprotein-antibody-associated disorder: a new inflammatory CNS demyelinating disorder. J Neurol 2021; 268:1419-33. [PMID: 33188477 DOI: 10.1007/s00415-020-10300-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/28/2020] [Accepted: 11/01/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIMS Myelin oligodendrocyte glycoprotein (MOG) is an oligodendrocytopathy resulting in demyelination. We aimed to determine the frequency of MOG-associated disorders (MOGAD), its various clinical phenotypes, and imaging characteristics. METHODS All patients with MOGAD were included. Description of the various clinical phenotypes, investigation profile, therapeutic response, differences between pediatric and adult-onset neurological disorders, determination of poor prognostic factors was done. RESULTS The study population consisted of 93 (M:F = 45:48) (Pediatric:40, Adult-onset:47, Late-onset:7) patients with a median age of 21 years. Among the 263 demyelinating episodes; 45.8% were optic neuritis (ON), 22.8% were myelopathy, 17.1% were brainstem, 7.6% were acute demyelinating encephalomyelitis(ADEM), 4.2% were opticomyelopathy and 2.3% with cerebral manifestations. There was exclusive vomiting in 24.7% prior to onset of clinical syndrome, none of them had area postrema involvement. ADEM was exclusively seen in pediatric patients. Poor prognostic indicators included: (i) incomplete recovery from an acute attack, (b) brainstem syndrome, (c) ADEM with incomplete recovery, (d) MRI suggestive of leukodystrophy pattern, (e) severe ON, (f) ADEMON. CONCLUSIONS The Spectrum of MOG-associated disorders is wider affecting the brain (grey and white matter) and the meninges. There are various clinical phenotypes and MRI patterns, recognition of which may help in the determination of therapeutic strategies, and long-term prognosis.
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Freire-Álvarez E, Guillén L, Lambert K, Baidez A, García-Quesada M, Andreo M, Alom J, Masiá M, Gutiérrez F. COVID-19-associated encephalitis successfully treated with combination therapy. Clin Infect Pract 2020; 7:100053. [PMID: 33163956 PMCID: PMC7604011 DOI: 10.1016/j.clinpr.2020.100053] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 12/21/2022] Open
Abstract
A case of COVID-19 with clinical features of acute demyelinating encephalomyelitis. The patient was successfully treated with immunoglobulins and cytokine blockade. Acute encephalitis amenable to immunomodulation could be a feature of COVID-19.
Background Acute encephalitis can occur in different viral diseases due to infection of the brain or by an immune mechanism. Severe novel coronavirus disease 2019 (COVID-19) is associated with a major immune inflammatory response with cytokine upregulation including interleukin 6 (IL-6). We report a case presenting with acute encephalitis that was diagnosed as having severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with hyperinflammatory systemic response and recovered after therapy with immunoglobulins and cytokine blockade. Case report A 39-year-old-man was brought to the Emergency Department with drowsiness, mental disorientation, intermittent fever and headache. A brain magnetic resonance imaging showed extensive involvement of the brain including cortical and subcortical right frontal regions, right thalamus, bilateral temporal lobes and cerebral peduncles, with no leptomeningeal enhancement. Cerebrospinal fluid (CSF) showed a leukocyte count of 20/µL (90% lymphocytes), protein level of 198 mg/dL, and glucose of 48 mg/dL. SARS-CoV-2 was detected in nasopharyngeal swabs by reverse-transcriptase-PCR (RT-PCR) but it was negative in the CSF. Remarkable laboratory findings in blood tests included low lymphocyte count and elevated ferritin, IL-6 and D-dimer. He had a complicated clinical course requiring mechanical ventilation. Intravenous immunoglobulins and cytokine blockade with tocilizumab, an IL-6 receptor antagonist, were added considering acute demyelinating encephalomyelitis. The patient made a full recovery, suggesting that it could have been related to host inflammatory response. Conclusion This case report indicates that COVID-19 may present as an encephalitis syndrome mimicking acute demyelinating encephalomyelitis that could be amenable to therapeutic modulation.
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Affiliation(s)
- Eric Freire-Álvarez
- Neurology Department, Hospital General Universitario de Elche, Alicante, Spain
| | - Lucía Guillén
- Infectious Diseases Unit, Hospital General Universitario de Elche and Universidad Miguel Hernández, Alicante, Spain
| | - Karine Lambert
- Magnetic Resonance Imaging Unit, Radiology Department, Hospital General Universitario de Elche, Alicante, Spain
| | - Ana Baidez
- Neurology Department, Hospital General Universitario de Elche, Alicante, Spain
| | | | - María Andreo
- Infectious Diseases Unit, Hospital General Universitario de Elche and Universidad Miguel Hernández, Alicante, Spain
| | - Jordi Alom
- Neurology Department, Hospital General Universitario de Elche, Alicante, Spain
| | - Mar Masiá
- Infectious Diseases Unit, Hospital General Universitario de Elche and Universidad Miguel Hernández, Alicante, Spain
| | - Félix Gutiérrez
- Infectious Diseases Unit, Hospital General Universitario de Elche and Universidad Miguel Hernández, Alicante, Spain
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Alawadhi A, Saint-Martin C, Bhanji F, Srour M, Atkinson J, Sébire G. Acute Hemorrhagic Encephalitis Responding to Combined Decompressive Craniectomy, Intravenous Immunoglobulin, and Corticosteroid Therapies: Association with Novel RANBP2 Variant. Front Neurol 2018; 9:130. [PMID: 29593631 PMCID: PMC5857578 DOI: 10.3389/fneur.2018.00130] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/21/2018] [Indexed: 11/21/2022] Open
Abstract
Background Acute hemorrhagic encephalomyelitis (AHEM) is considered as a rare form of acute disseminated encephalomyelitis characterized by fulminant encephalopathy with hemorrhagic necrosis and most often fatal outcome. Objective To report the association with Ran Binding Protein (RANBP2) gene variant and the response to decompressive craniectomy and high-dose intravenous methylprednisolone (IVMP) in life-threatening AHEM. Design Single case study. Case report A 6-year-old girl known to have sickle cell disease (SCD) presented an acquired demyelinating syndrome (ADS) with diplopia due to sudden unilateral fourth nerve palsy. She received five pulses of IVMP (30 mg/kg/day). Two weeks after steroid weaning, she developed right hemiplegia and coma. Brain magnetic resonance imaging showed a left frontal necrotico-hemorrhagic lesion and new multifocal areas of demyelination. She underwent decompressive craniotomy and evacuation of an ongoing left frontoparietal hemorrhage. Comprehensive investigations ruled out vascular and infectious process. The neurological deterioration stopped concomitantly with combined neurosurgical drainage of the hematoma, decompressive craniotomy, IVMP, and intravenous immunoglobulins (IVIG). She developed during the following months Crohn disease and sclerosing cholangitis. After 2-year follow-up, there was no new neurological manifestation. The patient still suffered right hemiplegia and aphasia, but was able to walk. Cognitive/behavioral abilities significantly recovered. A heterozygous novel rare missense variant (c.4993A>G, p.Lys1665Glu) was identified in RANBP2, a gene associated with acute necrotizing encephalopathy. RANBP2 is a protein playing an important role in the energy homeostasis of neuronal cells. Conclusion In any ADS occurring in the context of SCD and/or autoimmune condition, we recommend to slowly wean steroids and to closely monitor the patient after weaning to quickly treat any recurrence of neurological symptom with IVMP. This case report, in addition to others, stresses the likely efficacy of combined craniotomy, IVIG, and IVMP treatments in AHEM. RANBP2 mutations may sensitize the brain to inflammation and predispose to AHEM.
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Affiliation(s)
- Abdulla Alawadhi
- Division of Pediatric Neurology, Department of Pediatrics, Montreal Children's Hospital, Montreal, QC, Canada
| | - Christine Saint-Martin
- Department of Medical Imaging, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Farhan Bhanji
- Pediatric Intensive Care Unit, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Myriam Srour
- Division of Pediatric Neurology, Department of Pediatrics, Montreal Children's Hospital, Montreal, QC, Canada
| | - Jeffrey Atkinson
- Division of Neurosurgery, Department of Surgery, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Guillaume Sébire
- Division of Pediatric Neurology, Department of Pediatrics, Montreal Children's Hospital, Montreal, QC, Canada
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Abstract
A young child with catastrophic neurological illness diagnosed as a rare variant of acute demyelinating encephalomyelitis (ADEM). She succumbed to her illness despite of aggressive and appropriate management. Malignant demyelinating encephalomyelitis should be considered in children who are refractory to the treatment of ADEM.
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Affiliation(s)
- Suman Kushwaha
- Department of Neurology, Pathology, Neurosurgery, Institute of Human Behaviour and Allied Sciences, New Delhi, India
| | - Ashutosh Gupta
- Department of Neurology, Pathology, Neurosurgery, Institute of Human Behaviour and Allied Sciences, New Delhi, India
| | - Neha Agarwal
- Department of Neurology, Pathology, Neurosurgery, Institute of Human Behaviour and Allied Sciences, New Delhi, India
| | - Sujata Chaturvedi
- Department of Neurology, Pathology, Neurosurgery, Institute of Human Behaviour and Allied Sciences, New Delhi, India
| | - Deepak Jha
- Department of Neurology, Pathology, Neurosurgery, Institute of Human Behaviour and Allied Sciences, New Delhi, India
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Horellou P, Wang M, Keo V, Chrétien P, Serguera C, Waters P, Deiva K. Increased interleukin-6 correlates with myelin oligodendrocyte glycoprotein antibodies in pediatric monophasic demyelinating diseases and multiple sclerosis. J Neuroimmunol 2015; 289:1-7. [PMID: 26616865 DOI: 10.1016/j.jneuroim.2015.10.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 09/23/2015] [Accepted: 10/05/2015] [Indexed: 11/18/2022]
Abstract
Acquired demyelinating syndromes (ADS) in children evolve either as a monophasic disease diagnosed as acute demyelinating encephalomyelitis (ADEM), transverse myelitis (TM) or optic neuritis (ON), or a multiphasic one with several relapses most often leading to the diagnosis of multiple sclerosis (MS) or neuromyelitis optica (NMO). These neuroinflammatory disorders are increasingly associated with autoantibodies against proteins such as aquaporin-4 in rare instances, and more frequently against myelin oligodendrocyte glycoprotein (MOG). Recently, in adult NMO patients, C5a levels were shown to be elevated in cerebrospinal fluid (CSF) during acute exacerbation. We investigated the CSF levels of anaphylatoxins and pro-inflammatory cytokines, and plasma MOG antibodies in onset samples from children with ADS. Thirty four children presenting with a first episode of ADS, 17 with monophasic ADS (9 with ADEM, 4 with TM and 4 with ON) and 17 with MS, who had paired blood and CSF samples at onset were included and compared to 12 patients with other non-inflammatory neurological disorders (OND). Cytokines and anaphylatoxins in CSF were measured by Cytometric Bead Array immunoassay. MOG antibody titers in plasma were tested by flow cytometry using a stable cell line expressing full-length human MOG. We found a significant increase in C5a levels in the CSF of patients with monophasic ADS (n=17) compared to OND (n=12, p=0.0036) and to MS (n=17, p=0.0371). The C5a levels in MS were higher than in OND without reaching significance (p=0.2). CSF IL-6 levels were significantly increased in monophasic ADS compared to OND (p=0.0027) and to MS (p=0.0046). MOG antibody plasma levels were significantly higher in monophasic ADS (p<0.0001) and, to a lesser extent, in MS compared to OND (p=0.0023). Plasma MOG antibodies and CSF IL-6 levels were significantly correlated (r=0.51, p=0.018). CSF C5a and IL-6 levels are increased in monophasic ADS but not in MS when compared to OND, suggesting that these markers may help to predict monophasic or relapsing fate of ADS at onset. MOG antibody titers, which were higher in monophasic ADS than in MS, correlated with IL-6 levels, but not with C5a, suggesting an association between MOG antibodies and neuroinflammation in pediatric ADS.
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Affiliation(s)
- Philippe Horellou
- Inserm, U 1184, Center for Immunology of Viral Infections and Autoimmune Diseases, Université Paris-Sud 11, CEA, DSV/iMETI, Division of Immuno-Virology, IDMIT, Faculté de médecine - 63, rue Gabriel Péri, 94276 Le Kremlin-Bicêtre Cedex, France.
| | - Min Wang
- Inserm, U 1184, Center for Immunology of Viral Infections and Autoimmune Diseases, Université Paris-Sud 11, CEA, DSV/iMETI, Division of Immuno-Virology, IDMIT, Faculté de médecine - 63, rue Gabriel Péri, 94276 Le Kremlin-Bicêtre Cedex, France
| | - Vixra Keo
- Inserm, U 1184, Center for Immunology of Viral Infections and Autoimmune Diseases, Université Paris-Sud 11, CEA, DSV/iMETI, Division of Immuno-Virology, IDMIT, Faculté de médecine - 63, rue Gabriel Péri, 94276 Le Kremlin-Bicêtre Cedex, France
| | - Pascale Chrétien
- Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Hôpital Bicêtre, Immunology Department, Le Kremlin-Bicêtre, France
| | - Ché Serguera
- CRC MIRCen, INSERM/CEA, Fontenay-aux-Roses, France
| | - Patrick Waters
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Kumaran Deiva
- Inserm, U 1184, Center for Immunology of Viral Infections and Autoimmune Diseases, Université Paris-Sud 11, CEA, DSV/iMETI, Division of Immuno-Virology, IDMIT, Faculté de médecine - 63, rue Gabriel Péri, 94276 Le Kremlin-Bicêtre Cedex, France; Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Pediatric Neurology department, National Referral Center for Neuro-Inflammatory Diseases in Children, Le Kremlin-Bicêtre, France
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Abstract
We present a middle-aged woman with a prior history of central nervous system (CNS) demyelinating disorder who presented with an acute onset quadriparesis and respiratory failure. The evaluation revealed distal renal tubular acidosis with hypokalemia and medullary nephrocalcinosis. Weakness persisted despite potassium correction, and ongoing evaluation confirmed recurrent CNS and long-segment spinal cord demyelination with anti-aquaporin-4 antibodies. There was no history of dry eyes or dry mouth. Anti-Sjogren's syndrome A antigen antibodies were elevated, and there was reduced salivary flow on scintigraphy. Coexistent antiphospholipid antibody syndrome with inferior vena cava thrombosis was also found on evaluation. The index patient highlights several rare manifestations of primary Sjogren's syndrome (pSS) as the presenting features and highlights the differential diagnosis of the clinical syndromes in which pSS should be considered in the Intensive Care Unit.
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Affiliation(s)
- Srinivas Rajagopala
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India
| | - Gurukiran Danigeti
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India
| | - Dharanipragada Subrahmanyan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India
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Sidhu J, Maheshwari A, Gupta R, Devgan V. Acute Disseminated Encephalomyelitis After Plasmodium Vivax Infection: Case Report and Review of Literature. Pediatr Rep 2015; 7:5859. [PMID: 26266032 PMCID: PMC4508623 DOI: 10.4081/pr.2015.5859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 03/05/2015] [Accepted: 03/06/2015] [Indexed: 11/23/2022] Open
Abstract
Acute demyelinating encephalomyelitis (ADEM) usually occurs after viral infections or vaccination. Its occurrence after Plasmodium vivax infection is extremely uncommon. We report the case of an 8-year-old girl who had choreo-athetoid movements and ataxia after recovery from P.vivax infection. Diagnosis of ADEM was made on the basis of magnetic resonance imaging findings. The child responded to corticosteroids with complete neurological recovery.
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Affiliation(s)
- Jasmeet Sidhu
- Department of Pediatrics, North Delhi Municipal Corporation Medical College, Hindu Rao Hospital , New Delhi, India
| | - Anu Maheshwari
- Department of Pediatrics, North Delhi Municipal Corporation Medical College, Hindu Rao Hospital , New Delhi, India
| | - Raju Gupta
- Department of Pediatrics, North Delhi Municipal Corporation Medical College, Hindu Rao Hospital , New Delhi, India
| | - Veena Devgan
- Department of Pediatrics, North Delhi Municipal Corporation Medical College, Hindu Rao Hospital , New Delhi, India
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