Acute Disseminated Encephalomyelitis (ADEM) After Consecutive Exposures to Mycoplasma and COVID Vaccine: A Case Report


Acute disseminated encephalomyelitis (ADEM) is an autoimmune demyelinating illness of the central nervous system, generally triggered by viral infections or after immunization. ADEM occurrences in adults are uncommon. Full spectrum of problems is unknown for novel extreme acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccines.

A beforehand wholesome 44-year-old feminine introduced to the emergency room (ER) with acute onset of tingling, numbness, and weak spot of each decrease extremities, urinary retention, blurred imaginative and prescient in proper eye, and midline decrease again ache. Bodily examination revealed bilateral decrease extremity weak spot 1/5, absent deep tendon reflexes, and decreased sensation. She obtained the primary dose of SARS-CoV-2 vaccine six days previous to presentation to ER. Imaging of her lumbar backbone and head have been per an energetic demyelinating plaque per demyelinating illness both a number of sclerosis (MS) or ADEM. The affected person was began on SoluMedrol 500 mg IV twice each day for 5 days. Serological workup and CSF evaluation have been nonsignificant aside from Mycoplasma pneumonia IgM, elevated myelin primary protein, and constructive IgG, IgA, and IgM. Affected person steadily improved and was transferred to rehabilitation. Repeat MRI mind and backbone confirmed enchancment in earlier lesions. Nonetheless, she had worsening left eye signs that prompted her switch to a different facility for plasmapheresis. Plasma trade was carried out for 5 therapies for ADEM. Affected person began noticing enchancment in imaginative and prescient and was discharged on steroid taper.

We report a case of a doable affiliation between ADEM and SARS-CoV-2 mRNA vaccine. It needs to be thought-about within the differential analysis in any case suggestive of acute demyelination after COVID-19 vaccination.

Introduction

Acute disseminated encephalomyelitis (ADEM) is a neurological manifestation attributed to inflammatory demyelination of the central nervous system. A number of theories have been proposed to clarify the mechanisms of ADEM. One rationalization is cross-reaction between viral protein and nervous system (myelin auto-antigens) [1]. One other idea attributes ADEM to irritation and circulating complexes that follows an infection or vaccinations resulting in vascular permeability and congestion within the central nervous system [1].

Early onset of manifestations is often accelerated neurological signs relying on the extent of mind affected. Signs embody altered psychological standing (AMS) with mixture of both higher motor neuron (UMN) or decrease motor neuron (LMN) lesion or each. Sure circumstances could be accompanied by generalized signs comparable to fever, physique ache, and many others. [1]. ADEM occurrences are extra prevalent in kids than in adults [2]. Earlier than immunization packages, ADEM was generally attributed to viral or bacterial an infection, then later, extra ADEM occurrences have been reported inside eight to 21 days of vaccination [1]. On this case, we reported ADEM submit subsequent mycoplasma detection and SARS-CoV-2 mRNA vaccination.

Case Presentation

A 44-year-old feminine with previous medical historical past of tension, hyperlipidemia, renal stone, and hypothyroidism got here to the emergency room (ER) with complaints of numbness and weak spot in each legs. The affected person reported that she was utterly properly, and he or she takes levothyroxine each day. The day before today, she went to a therapeutic massage therapist, and the following day she began having tingling and numbness together with weak spot in each decrease extremities, she additionally endorsed urinary retention, blurred imaginative and prescient in proper eye, and midline decrease again ache. Signs steadily acquired worse till she was barely capable of transfer each decrease extremities, she acquired involved with all these and got here to ER. On arrival, her very important indicators have been steady. Bodily examination confirmed muscle power 1/5, 0 deep tendon reflexes of bilateral decrease extremities, bilateral and equal diminished sensation to the touch and pinprick, and sensory degree at T3. Gait couldn’t be checked since she wasn’t capable of stand, remainder of the bodily examination was in any other case regular. She denied fever, chills, headache, nuchal rigidity, nausea, vomiting, chest ache, shortness of breath, hassle with speech, facial droop, any trauma, current an infection, or comparable complaints previously. She did obtain SARS-CoV-2 mRNA vaccine first dose six days previous to presentation. She reportedly was working in a nursing house, was getting examined for coronavirus illness 2019 (COVID-19) by polymerase chain response (PCR)-RNA take a look at twice weekly, and by no means had a constructive consequence. Preliminary labs have been vital for delicate leucocytosis at 12.1 x1,000/mL, serum Okay of three.4 mEq/L. T2 MRI lumbar backbone with and with out distinction was accomplished, which confirmed a 12 mm lesion in conus at T11-12 degree per an energetic demyelinating plaque. CT head with out distinction confirmed a 2.4 cm low-density mass in anterior left frontal lobe together with a number of supratentorial and infratentorial lesions per demyelinating illness both a number of sclerosis (MS) or acute disseminated encephalomyelitis (ADEM). Affected person was began on SoluMedrol 500 mg IV twice each day for 5 days, and lumbar puncture and additional labs have been carried out (Desk 1), and speech and swallow evaluations have been carried out as properly; she didn’t have any indicators or signs of aspiration. T2 MRI mind, cervical and thoracic backbone with and with out distinction confirmed multifocal supratentorial predominantly periventricular lesions with a single lesion in proper higher cervical twine and an enhancing 17 mm lesion in left frontal white matter with surrounding edema, once more findings per demyelinating illness (Determine 1). Multifocal and diffuse irregular central twine sign depth starting at C3-C4 extending into thoracic backbone with focal sparing at C5-C6. Diffuse irregular central twine sign depth all through thoracic backbone was favoring ADEM contemplating current MRI mind findings (Determine 2). Additional workup was carried out to rule out different potential diagnoses and causes of ADEM.

Take a look at End result Reference vary
Glucose, CSF 66 40-70 mg/dL
Protein, CSF 98 15-40 mg/dL
RBC, CSF 7 0-5 cells
WBC, CSF 105 0-10 cells
VZV DNA, CSF Not detected
Cryptococcus antigen, CSF Adverse
VDRL/RPR, CSF Non-reactive
West Nile Ab IgG, CSF <1.30
West Nile Ab IgM, CSF <0.90
Meningoencephalitis panel, CSF Adverse
NMO antibody, CSF Adverse
ACE, CSF 6 ≤15 p/mol/L/min
Lyme antibody, CSF Adverse
Malignant cells, CSF Adverse
Myelin primary protein, CSF 10.2 2.0-4.0 mcg/L
IgG, CSF 11.6 0.8-7.7 mg/dL
IgA, CSF 1.8 <0.6 mg/dL
IgM, CSF 1.8 <0.5 mg/dL
Albumin, CSF 59 8.0-42.0 mg/dL
Oligoclonal bands, CSF No bands
CMV IgM Ab <30 <30 mg/dL
Mycoplasma pneumonia Ab, IgG 4.07 ≤0.90 mg/dL
Mycoplasma pneumonia Ab, IgM 1,943 <770 mg/dL
VDRL/RPR Non-reactive
COVID-19 IgG 0.09 <1.39 mg/dL
EBV DNA qPCR 693 <200 IU/mL
HIV Non-reactive
Flu A Adverse
Flu B Adverse
CMV qPCR Adverse
HSV 1 Adverse

Oral steroid was began after finishing 5 days of IV steroids, she was began on 60 mg oral prednisone that was tapered by half each three days. Gabapentin and baclofen have been began as wanted for again ache as properly. Affected person steadily confirmed sluggish enchancment, was capable of wiggle her toes and later transfer her toes and was medically steady sufficient to go to rehab.

She nonetheless had bilateral decrease extremity weak spot, tingling and numbness, blurred imaginative and prescient in proper eye, and urinary retention. On day eight since admission, affected person had acute worsening blurred imaginative and prescient in left eye (blurry imaginative and prescient of proper eye by no means improved) throughout her rehab keep and was transferred to a different facility for plasmapheresis on day 9 from admission.

Plasma trade was deliberate for 5 therapies for acute disseminated encephalomyelitis (ADEM), affected person began noticing enchancment in visible and urinary signs. Repeat T2 MRI mind, cervical and thoracic backbone with and with out distinction in 14 days confirmed enchancment, earlier lesions appeared to lower in measurement or resolved. she was discharged on steroid taper with recommendation to observe up with ophthalmology, urology, and neurology as outpatient. Urinary retention utterly resolved, per neuro-ophthalmology, affected person possible had optic neuritis which resolved to optic atrophy. Visible subject take a look at confirmed blind spot, ceco-central scotoma in each eyes.

Six months later repeat T2 MRI mind and backbone with and with out distinction have been carried out and confirmed decision of beforehand reported demyelinating lesions and no new demyelinating lesions (Figures 3, 4). Repeat ophthalmological analysis was steady.

Dialogue

ADEM is an immunologically mediated demyelinating illness triggered by an an infection or current vaccination, eliciting an inflammatory response affecting the central nervous system (CNS). ADEM is extra prevalent in kids and younger adults and is regarded as associated to the elevated frequency of viral infections and vaccination in that age group [3]. The estimated incidence of ADEM is one in 125,000 to 250,000 people yearly, it’s extra frequent in males than females [1]. Worldwide Pediatric A number of Sclerosis Research Group has proposed the diagnostic standards for ADEM. The most important standards are scientific assault of CNS demyelinating illness with acute or subacute onset, polysymptomatic neurologic options, and encephalopathy [4]. Impairment of consciousness is current in 46-73% of pediatric sufferers and in 20-56% of grownup circumstances [1].

After acquiring an in depth historical past and bodily examination, sufferers with suspected ADEM ought to get MRI of the mind, cervical and thoracic backbone with out distinction. Laboratory evaluations of CSF and serum needs to be obtained primarily to rule out different doable causes, comparable to an infection, a number of sclerosis (MS), neuromyelitis optica spectrum dysfunction, and myelin oligodendrocyte glycoprotein (MOG) antibody-associated dysfunction. ADEM presents with typical mind lesions in MRI that are diffuse, ill-defined, symmetric, irregular, and sometimes patchy with areas of homogeneous sign hyperintensities involving each the grey and white matter [5]. Lumbar puncture might reveal abnormalities in 50-80% of sufferers with ADEM. These findings might embody lymphocytic pleocytosis and a barely elevated CSF protein. Extra particularly, sufferers with ADEM are sometimes seen to have an elevated degree of myelin primary protein on CSF evaluation indicating acute demyelination [6].

Our affected person introduced with a number of neurological deficits, motor deficit, acute urinary retention, and blurred imaginative and prescient. Though she didn’t have altered psychological standing (AMS) which is among the diagnostic standards in keeping with the Worldwide Pediatric A number of Sclerosis Research Group, she had demyelinating lesions on MRI mind, cervical and thoracolumbar backbone and elevated myelin primary protein on CSF [4].

In case of MS extra possible sufferers current with monosymptomatology and often optic neuritis is unilateral, they do not have basic signs or inflammatory markers elevated on labs. CSF evaluation can present pleocytosis and constructive oligoclonal bands [6]. MRI findings often have well-demarcated borders, preliminary imaging can reveal outdated lesions, and repeat MRI in six months can present new demyelinating lesions. This was not evident in our affected person [6].

The affected person had a historical past of current mRNA COVID vaccine administration and he or she examined constructive for mycoplasma pneumonia IgM and IgG. It will have been helpful to verify for affected person’s CSF, nasopharyngeal mycoplasma PCR, or CSF mycoplasma tradition, to have the opportunity to find out if that is confirmed, indeterminate, or doable mycoplasma-related ADEM [7]. 4-fold improve in serum Abs along with CSF PCR is confirmatory for acute mycoplasma an infection however it isn’t sensible in acutely essential circumstances [8]. Intrathecal mycoplasma pneumonia Ab detection is an rising promising take a look at for mycoplasma encephalitis [8]. Constructive mycoplasma IgM and IgG is suggestive of an publicity to mycoplasma inside the final two months. Nonetheless, the affected person denied any prodromal to counsel current viral or bacterial an infection, and chest examination and imaging have been clear. There’s literature suggesting doable mycoplasma pneumonia affiliation with ADEM, with no proof of respiratory an infection, proof of co-infection was detected in 45% and 93% of possible and indeterminate mycoplasma encephalitis, respectively [7].

The timeline suggests consecutive doable an infection by mycoplasma after which mRNA COVID vaccine administration. This might symbolize synergistic impact from the 2 insults resulting in ADEM. Neurological negative effects following vaccination are typically delicate and non permanent, comparable to fever, chills, headache, fatigue, myalgia, arthralgia, or native injection results like swelling, redness, or ache. Essentially the most catastrophic neurological complication associated to SARS-CoV2 vaccine is cerebral venous sinus thrombosis [9]. One other neurological complication is Bell’s palsy which was associated primarily to mRNA vaccine administration [10]. Acute transverse myelitis, acute disseminated encephalomyelitis, and acute demyelinating polyneuropathy are different surprising neurological opposed occasions that happen because of molecular mimicry [11]. Reactivation of herpes zoster following administration of mRNA vaccines has been additionally recorded [11]. Literature evaluate revealed one reported case with ADEM post-COVID vaccination, later obtained a SARS-CoV-2 vaccine, together with 4 μg inactivated SARS-CoV-2 (Vero Cells; Beijing, China: Beijing Institute of Organic Merchandise Co., Ltd.) two weeks earlier than onset of ADEM signs [12].

Remedy choices are primarily based on observational research. First line of therapy for ADEM is high-dose IV corticosteroids, adopted by tapered oral prednisolone. Intravenous immunoglobulin (IVIG) is taken into account in steroid unresponsive sufferers or in sufferers who’ve contraindications to steroids administration [13]. Plasmapheresis (PLEX) is reserved for refractory fulminant circumstances. As defined above on this case, the affected person obtained IV steroids and 5 periods of PLEX when she had worsening visible signs.

Conclusions

Herein, we mentioned a case of ADEM following COVID mRNA vaccine administration and mycoplasma detection. ADEM needs to be thought-about within the differential analysis of any case introduced with a suggestive scientific image after COVID vaccine administration. Furthermore, cautious immunization historical past is critical in any case introduced with ADEM. Extra research are wanted to establish if there may be a relation between COVID vaccination and ADEM.





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