FIG 1:-MRI of brain showing T2 AND FLAIR view of temporo-parietal region
So she was diagnosed as case of ADEM and was treated accordingly with i/v methylprednisolone 20mg/kg body weight for 5 days followed by oral corticosteroids in tapering dose for 6 weeks.
Discussion
ADEM commonly referred to as post infectious encephalomyelitis affects the central nervous system and is characterised by demylination of the brain and spinal cord. (1) A rare autoimmune disorder known to be affecting 1 in 1,25,000-1,50,000 population most commonly affects the younger age group (2),presents with symptoms ranging initially from non specific such as fever, nausea, vomiting, fatigue, lethargy, irritability, malaise, nausea, weight loss, confusion, stupor and coma.(9)The specific neurological symptoms comprise of leg/arm weakness, tingling or numbness, Seizures,altered mental status, vision loss as it occasionally involves the optic nerve(1,9).The extent of presentations vary between the affecting individuals depending on the age of onset and the location of the lesions (9). In the later stages the patients can also present with ataxia, slurring of speech and cranial nerve dysfunction.(1,2,9) Our patient presented with fever, headache and one episode of seizure with altered mental status, loss of consciousness, reduced GCS , signs of meningeal irritation bilateral plantar extensor mimicking meningoencephalitis.She was treated with empirical antibiotics and antiviral for meningoencephalitis. According to Suvasini sharma et al(10) headache and vomiting are reported in 38 to 52% of the patients, seizure in 13 to 47% , meningismus in 5 to 43%. Fever and seizure are more frequently associated with ADEM as compared to other demyelinating syndromes.(10) Seizures are common ranging from focal togeneralised(7).The exact pathophysiology isn’t understood but it is most commonly considered to be associated with immune response following infections or vaccination .(1,2,9) There is no specific diagnostic criteria, a good history, clinical examination and relevant examination findings helps the establishment of the diagnosis. In two third of patients abnormal CSF findings are seen i.e. moderate pleocytosis with raised proteins and absence of oligoclonal bands.(7) MRI of the brain shows hyperintense lesion on T2 weighted, FLAIR, proton density and  echo planar trace diffusion free sequences.(1)ADEM can also present as space occupying lesion( SOL) (7) involvement can be present either as a single lesion or in the form of multiple lesions .(1). Our patient’s CSF findings were normal  but the MRI of brain showed multiple abnormal T2 hyperintense signal in both parieto-frontal white matter.Treatment Options include high dose corticosteroids preferably methylprednisolone and dexamethasone.Intravenous immunoglobulin(IVIG) can be considered if the patient doesn’t respond to steroids.Clinical trials also suggest plasmapheresis to be considered as one of the treatment Options. Rehabilitation therapy should be considered for those having cognitive or speech impairment, epilepsy , visual and motor problems (7). We started high dose IV methylprednisolone for our patient and she showed dramatic improvement following the treatment which was later followed by oral steroids. Clinical progress of ADEM is rapidly progressive with rapid deterioration within 2 to 5 days.Rarely owing to brain stem involvement, respiratory failure may occur (10) Children usually have a good prognosis but severe cases may have residual abnormalities, one fourth of the cases havea poor prognosis(8). On the first follow up our patient had mild generalised weakness otherwise she was normal.on the 2nd follow up after 2 weeks , she was completely fine with no any residual abnormalities. Conclusion
Though ADEM is a rare autoimmune neurological disorder with a incidence of 1 in 125,000 -250,000 it still can be treated by early diagnosis and treatment. The main goal of the authors here is to highlight a case of ADEM and where eary diagnosis and treatment was beneficial for the patient. Children are the ones who are affected by ADEM so it is very much crucial to suspect ADEM for early and diagnosis and treatment. After covid-19 and its vaccination cases of ADEM are increasing so we must keep in mind it can be ADEM if there will be presentation like that of this case.
Conflict of interest-None to disclose
Fundings-The authors didn’t receive any fundings for the paper.
Author contribution- The first author contributed to writing the first draft of manuscript and literature review and all the other authors contributed to critically reviewing and revising for the final publication.
References
1. Anilkumar, A. C., Foris, L. A., & Tadi, P. (2023). Acute Disseminated Encephalomyelitis . StatPearls Publishing.Available from: https://www.ncbi.nlm.nih.gov/books/NBK430934/