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.
Allergies: Penicilllin (rash)
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%)
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.
- 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