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Título

Atypical presentation of Acute Disseminated Encephalomyelitis (ADEM) in adult after SARS-Cov-2 infection

RESUMO

Case Presentation: A 31-years-old man, gardener, previously obese and hypertensive, presented with binocular diplopia associated with SARS-Cov-2 infection. After two weeks, he presented gait abnormalities and nauseas with progressive worsening of symptoms, and onset of peripheral facial paralysis. The patient was admitted to Emergency Department for investigation, and the neurological examination showed right dysmetria, cerebellar gait, horizontal nystagmus with fast phase to the right, and right peripheral facial palsy. CT in admission was normal. Extensive laboratory tests were normal. CSF has been showed protein 83mg/dL and 2 cells. MRI showed in FLAIR and T2 a periaqueductal hypersignal at midbrain-bridge transition, in the posterior region of the midbrain and cerebellar vermis. On T1 contrast, there was gadolinium enhancement. Neoplastic screening revealed no signs of tumor. Then the patient was treated with intravenous methylprednisolone 1000mg/d each for 5 consecutives days. After 5 days, the neurological examination showed gait and cerebellar tests normal, with persistence of mild facial palsy. New brain MRI showed significant improvement in aspect of the lesion, with mild hypersignal in cerebellar vermis.
Discussion: ADEM is a rare demyelinating disease more commonly seen in children, presenting clinical heterogenic, generally causing encephalopathy and multifocal deficits. Several studies reported an increased incidence of ADEM after SARS-CoV-2 epidemics. In the typical presentation of ADEM, neurological symptoms develop 7–14 days following an infection and may involve headache, emesis, behavior alterations and coma. The case reported showed dysmetria, cerebellar gait, nauseas and facial palsy. ADEM CSF examination reveals inflammatory findings, consisting of elevated protein levels and lymphocytic pleocytosis. Isolate increased protein level was present in up 40% of ADEM linked to SARS-Cov-2 in some case series. A few atypical presentations can be seen in some cases, and the differential diagnosis with multiple sclerosis (MS) remains challenging due to the overlap in the clinical presentation. In ADEM, the lesions can be seen in the brainstem and cerebellum, resulting in symptoms that are like those found in the present case.
Final comments: The varied clinical manifestations caused by SARS-Cov-2 infection in the nervus system have been constantly updated. In this context, coronavirus infection can be seen as a trigger to ADEM.

Palavras Chave

SARS-Cov-2, ADEM