Acute Disseminated Encephalomyelitis after endophthalmitis in immunosuppresed patient

Abstract

Context: Acute Disseminated Encephalomyelitis (ADEM) usually happens after an infectious event, vaccination reaction and with history of immunosuppression. Clinical features can be varied: headache, fever, seizure, blurred vision, ataxia, motor deficits and mental confusion. Case report: A 35-yearsold woman, in a social risk situation, complained about pain and blurred vision, history of cocaine abuse, victim of sexual and physical abuse and recent Measles vaccination. She had corneal ulcer with bilateral endophthalmitis and optic nerve infection. Despite intravitreal injections of Vancomycin + Ceftazidime, patient had to eviscerate the left eye. After surgery, patient evolved with mental confusion and paraparesis, CSF cell 69, lymphomonocyte, proteins 257, MRI showed central bulbar hyperintensity, lesions in the dentate nucleus and periaqueductal of gray substance in T2 / FLAIR, thoracic and lumbar spine with demyelinating pattern, extensive longitudinal myelitis. Patient obtained clinical improvement after treatment with Methylprednisolone 1gr for 5 days. It is important to discard other hypothesis: transverse myelitis, neuromyelitis optica, multiple sclerosis and systemic lupus erythematosus. The diagnosis is clinical and radiological with multifocal and confluent areas of hypersignal on MRI, CSF analysis reveals high protein and lymphocytic pleocytosis. Treatment with Methylprednisolone is the first choice and then Plasmapheresis. Conclusion: there are several risk factors for the development of ADEM correlated with a rapid and aggressive evolution in this patient.