Acute Disseminated Encephalomyelitis (ADEM)—A Rare Complication of Falciparum Malaria

Abstract

A 4-y-old girl was admitted with fever and altered sensorium. Peripheral blood smear and quantified buffy coat test showed Plasmodium falciparum infection. She received antimalarial therapy and got discharged on seventh day without any neurological deficit. Seven days later she was readmitted with fever and disorientation. Neurological examination revealed coma and decerebration. The deep tendon reflexes were exaggerated and babiniski response was positive in the right lower limb. MRI of brain revealed multifocal asymmetrical T2W/FLAIR hyperintensities in cerebral hemispheres, sub cortical white matter and midbrain. There was minimal patchy enhancement on contrast study. Any feature of grey matter involvement was not observed. The child improved remarkably after the treatment with methyl prednisolone. A follow up MRI after one year showed a complete resolution of demyelinating lesions. Diagnosis of acute disseminated encephalomyelitis (ADEM) as a complication of falciparum malaria was made based on sudden onset of neurological events, MRI findings and prompt response to corticosteroid therapy.

Psychiatric effects of malaria and anti-malarial drugs: historical and modern perspectives

“…Similarly, in cases of ADEM, although neurological findings tend to predominate, psychiatric symptoms including alterations in sensorium [ 62 ], confusion [ 63 ], disorientation [ 64 ], and language difficulties have been reported [ 65 ].…”

A spectrum of inflammation and demyelination in acute disseminated encephalomyelitis (ADEM) of children

“…Also enterovirus [23], coronavirus [24], human immunodeficiency virus [2], herpes simplex virus [25], cytomegalovirus [22], and hepatitis A virus [26,27] have been associated with ADEM. Other pathogens anecdotally involved in ADEM have been Toxoplasma gondii [3], Plasmodium falciparum [28], Cryptococcus neoformans [29], Haemophilus influenzae type b [30], Leptospira sp. [31], Streptococcus pyogenes [32], Borrelia burgdorferi [33], atypical bacteria (i.e., Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila) [13], Rickettsia sp.…”

“…Cases of fulminant ADEM, such as acute hemorrhagic leukoencephalitis or forms complicated by severe brain edema, could be treated with mild hypothermia therapy, in which body's temperature is reduced to 34°C and intracranial pressure and cerebral perfusion pressure levels maintained low using mannitol and dopamine [24,28]. In selected cases with persistently high intracranial pressure a decompressive craniectomy could be performed [88].…”

Acute demyelinating encephalomyelitis in malaria

“…We therefore suggest an outpatient protocol for changing these patients from insulin to Sulfonylureas(SUs) [2]. SUs are introduced gradually over a period of weeks as an outpatient.…”