Abstract
We present a case of multiphasic ADEM associated with both human metapneumovirus and influenza type A (swine specific H1N1) with good recovery after treatment with methylprednisolone and oseltamivir. A 60-year-old Ghanaian man presented with 1-week history of intermittent fevers, pleuritic chest pain and cough productive of blood-stained sputum. He had not left the country for 20 years and had not had any recent illnesses or vaccinations. On admission he was in type 1 respiratory failure with widespread consolidation throughout both lung fields. He was intubated, ventilated and commenced on antibiotics for bilateral community-acquired pneumonia. Human metapneumovirus RNA was isolated from his sputum. He improved but on day 11 became acutely confused with weakness in his left-sided limbs. There was increased tone, and absent ankle reflexes and a left extensor plantar response. Magnetic resonance imaging (MRI) brain showed bilateral multiple hyperintense lesions in the white matter of both hemispheres and right cerebral peduncle consistent with ADEM (Fig. 1). Lumbar puncture was normal; oligoclonal bands were not present. Electroencephalogram (EEG) was consistent with underlying encephalopathy. He was treated with a 5-day course of pulsed iv methylprednisolone followed by 60 mg prednisolone. He made a significant improvement and was discharged 2 months later with little residual neurological deficit. He re-presented 5 months later complaining of 1 week of coryzal symptoms, headaches and intermittent fevers. On examination, he had bilateral pneumonia and type 1 respiratory failure. He was intubated and ventilated. Initial virology screening was positive for influenza type A (swine specific H1N1), and he received 5 days of oseltamivir. He made a good improvement and was extubated after 4 days. However, on day 18, he became acutely confused. Examination revealed a pseudo-pyramidal pattern of weakness in the lower limbs, worse on the left. MRI brain scan showed maturation of the previous white matter lesions, with new lesions in the pons and midbrain tegmentum: changes consistent with recurrence of ADEM (Fig. 2). He was given 1 g pulsed iv methylprednisolone for 5 days followed by 60 mg prednisolone. He improved and was discharged following 3 months of neuro-physiotherapy. ADEM is a rare autoimmune demyelinating disorder with preceding viral or bacterial infection in approximately 50–70% of cases [1–5]. A wide range of pathogens have been reported, including Epstein–Barr virus, measles and herpes, but this is the first reported case of ADEM associated with both human metapneumovirus and influenza type A (H1N1). MRI has high sensitivity for lesion detection. It can also be used to exclude differential diagnoses such as neuromyelitis optica (which has spinal lesions extending over three or more segments). Lesions in ADEM are frequently evident on T2-weighted or fluid attenuated inversion recovery (FLAIR) images. They are typically large, multiple and asymmetric, and usually involve the subcortical and central white matter and cortical grey–white junction of cerebral hemispheres, cerebellum, brainstem and spinal cord. Lesions are not confined to white matter but may involve the cortical and deep grey matter, including the thalami and basal ganglia [6]. ADEM is traditionally considered a monophasic illness; however, numerous case reports and studies describe D. Athauda T. C. Andrews P. A. Holmes R. S. Howard (&) Department of Neurology, Guy’s and St. Thomas’ NHS Trust, London SE1 7EH, UK e-mail: robin.howard@gstt.nhs.uk
Published Version
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