22 Sep 2021

5/13/21: Acute Demyelinating Encephalomyelitis (ADEM) 2/2 COVID

PGY3 Jennifer Tang presented a case of a 45 y/o M with no significant past medical history who was brought in by wife for 1 week of gait instability, forgetfulness and global weakness.  Most of history obtained from wife as patient was A&Ox2 during the history gathering.  Wife reports that the patient was having frequent falls 2/2 instability with no loss of consciousness or trauma to the head.  Denies headache, vision change, dysphagia, dizziness, dysarthria, changes in sensation and numbness/tingling.

Prior to symptom onset, patient was fully functional, employed and able to do ADLs.  He was diagnosed with COVID 1 month prior with residual symptoms of cough, fatigue and weakness.

Meds: none

Allergies: Penicilllin (rash)

FH: none

SH: Lives with wife.  Works as a construction worker, able to perform ADLs.  Denies tobacco/ethanol/drug use.

Vitals: T 36.5, HR 111, RR 18, BP 154/100, O2 sat 100% on RA

Physical Exam: A&O x2 (name and location), normal cardiac and pulmonary exams.  Intermittent nonsensical speech, +perseveration, +some difficulty following verbal commands.  CN II-XII grossly intact, +5/5 strength in all extremities but subtle action and at rest, low amplitude tremor in bilateral hands, intact sensation, intact reflexes, finger to nose slow, no tremors.

CBC: WBC 5.9>Hb 15.4/Hct 45.4 <Plt 279 (MCV 84, RDW 13.3%)

CMP:

Na 137/K 4.4/Cl 103/HCO3 24/BUN 13/Cr 0.8<Glucose 96

ALP 81>T.protein 7.1/Albumin 4.4/AST 14/ALT 24/Tbili 0.4/Dbili <0.2

Ca 9.6, Mg 2.2, Phos 3.6

PT 13.5, INR 1.04, PTT 32.1

Infectious workup initiated with negative findings of the following: BCx, Fungal Culture, UA, HIV, EBV, fungal (blasto, cocci, histo, crypto), COVID-19, and hepatitis panel. 

LP performed with opening pressure of 23, 1 RBC, 2 nucleated cells, occasional lymphocytes, 61 protein and 62 glucose.  CSF cytology, culture and fungal studies were negative

Toxicology screens with Utox, alcohol level, Tylenol level and aspirin all negative.

Pan-scan CT chest/abdomen/pelvis did not reveal any abnormal findings.

TTE and TEE negative for vegetations.

EEG: diffuse background slowing.

CTH: multiple scattered hypodensities involving the supratentorial subcortical and deep while matter

MRI Head w/ and w/o contrast: Innumerable predominately supratentorial enhancing lesions involving the subcortical, and deep white matter and involving the corpus callosum.

Treatment: Given the above findings, patient was started on on solumedrol 1g IV x5 days for concern of ADEM 2/2 COVID with no clinical improvement.  He then was started on PLEX x5 doses and demonstrated significant improvement in mental status and upon discharge, he was A&Ox4 and could follow 2 step commands and able to speak in complete, logical sentences.  Patient was seen in clinic a month later with his neuro function back to baseline and interval MRI showed improvement in his lesions.

Teaching points:

  • ADEM is a rare immune-mediated demyelinated CNS disorder mor commonly in children and typically occurs post infection.
    • MRI: b/l, asymmetrical brain lesions on MRI in the supratentorial or infratentorial white matter on T2 weighted sequences
    • Diagnosis of exclusion
    • Tx: steroids or PLEX
Paterson RW,  Brown RL,  Benjamin L, et al The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings. Brain. : 2020;143:3104 20.doi:10.1093/brain/awaa240 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32637987

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