Elsevier

Journal of Neuroimmunology

Volume 349, 15 December 2020, 577405
Journal of Neuroimmunology

Short Communication
Covid-19 systemic infection exacerbates pre-existing acute disseminated encephalomyelitis (ADEM)

https://doi.org/10.1016/j.jneuroim.2020.577405Get rights and content

Highlights

  • COVID-19 infection can exacerbate an acute disseminated encephalomyelitis (ADEM) attack.

  • Early recognition of ADEM in the setting of COVID-19 is crucial for early treatment.

  • Treated ADEM exacerbated by COVID-19 systemic infection carries a good prognosis.

  • Diagnosis of COVID 19-exacerbated ADEM depends on CSF viral testing.

  • Alternative methods to inpatient skilled nursing rehabilitation should be considered.

Abstract

Acute disseminated encephalomyelitis (ADEM) is an uncommon diagnosis in adults. It is known to be due to an abnormal immune response to a systemic infection rather than direct viral invasion to the central nervous system. There have been few reports of ADEM diagnosed in the setting of COVID-19 systemic infection. However, we report a case of Coxsackie induced ADEM that remitted but got exacerbated by COVID-19 infection. The patient contracted the COVID-19 infection shortly after being discharged to a rehabilitation facility. Direct COVID-19 neuroinvasion was ruled out via CSF PCR testing for the virus. The patient responded well to pulse steroid therapy and plasmapheresis in both occasions. We hypothesize that COVID-19 infection can flare-up a recently remitted ADEM via altering the immune responses. It is known now that COVID-19 infection can produce cytokine storming. Cytokine pathway activation is known to be involved in the pathology of ADEM. Caution regarding discharging immune suppressed patient to the inpatient rehabilitation facility should be made in the era of COVID-19 pandemic.

Keywords

COVID-19
Acute disseminated encephalomyelitis
ADEM
Exacerbation
Encephalopathy

Abbreviations

ADEM
acute disseminated encephalomyelitis
CSF
cerebrospinal fluid
EEG
electroencephalogram
MRI
magnetic resonance imaging
CT
computed tomography
FLAIR
fluid attenuated inversion recovery
RT-Quic
Real-time quaking-induced conversion
PCR
polymerase chain reaction
IVIG
intravenous immunoglobulins
RCVS
reversible cerebral vasoconstriction syndrome;
PRES
posterior reversible encephalopathy syndrome.

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