Management of a unique case of acute disseminated encephalomyelitis (ADEM) in a lowresource setting

Clinical findings: NC, a 20-month-old male presented in July 2020 with new-onset focal motor seizures, drowsiness and developmental regression There was a preceding history of fever, vomiting and diarrhoea about 1 to 2 weeks prior to presenting On examination, he was noted to have erythema nodosum over his shins, unable to fix and follow even to light stimulus, no head nor trunk control with generalized increased tone, hyperreflexia and upgoing plantar responses bilaterally Investigations: Blood investigations: lymphopenia, mild increase in ESR 16mm/hr, transaminases elevated, CK elevated CSF investigations: CSF protein 143mg/dL, glucose 88mg/dL, CSF cell count 28 white cells, 17 red cells EEG: background slowing right > left MRI brain (initial): transient lesions along corpus callosum, petechial haemorrhages within superior aspect of cerebellar vermis Treatment: He was treated with 5 days IV methylprednisolone 30mg/kg/day followed by oral prednisolone He was treated as a protracted ADEM illness with IVIG (2g/kg over 2 days) when he clinically deteriorated Steroids were slowly tapered over 8 weeks Progress: 2 weeks post IVIG-speech and language milestones improved to baseline, started cruising 6 weeks post IVIG-able to walk independently however, not able to climb/run Follow-up investigations: 2 months post admission: 2019-CoV IgM Antibodies (blood): 1 123 (range 0-1) Of note, we have had a total of 4 patients managed for ADEM within the past 3 months 3 presented with preceding viral GE symptoms Most recently the other was initially managed for Kawasaki disease and is also COVID 19 IgM positive We are awaiting COVID-19 antibody testing for these patients to determine whether they are linked Unfortunately, in our resource-limited setting, PCR testing was initially only performed on patients with a travel history and respiratory symptoms