Author Response: Teaching Video NeuroImages: Pathologic Yawning: A Sign of Brainstem Involvement in Acute Disseminated Encephalomyelitis?

Abstract

We thank Drs. Fujimori and Nakashima for their comment on our article.1 Their previously published report is certainly an interesting case as well.2 We agree that anti-myelin oligodendrocyte glycoprotein antibody testing is appropriate to include in cases of suspected acute disseminated encephalomyelitis (ADEM). We ordered a broad inflammatory and infectious workup for our patient on both serum and CSF, with the latter being repeated 5 days after initial presentation. Oligoclonal bands were noted in the CSF on 1 of 2 tests. The CSF IgG index was elevated (0.80 initially and 0.68 on follow-up; reference range 0.34–0.66). Anti-AQP4 antibodies were negative. Infectious workup showed negative serology for Epstein-Barr virus and cytomegalovirus. Viral PCR (including enterovirus) was negative, as was CSF mycobacterial culture. Mycoplasma pneumoniae IgM was positive in serum. Bartonella henselae serum IgG was also positive (1:640), but this was not believed to be clinically relevant. We ordered anti-MOG antibodies at the time of initial presentation, but unfortunately these were canceled by the laboratory because of a registration error; we have not reordered the test because the patient has completely recovered and the lesions seen on brain MRI have resolved. At this point, M. pneumoniae infection is the most likely trigger for the ADEM.