Case report: A case of acute disseminated encephalomyelitis after SARS-CoV-2 infection in pediatric patients

Abstract

IntroductionSince the beginning, there has been enough evidence about the multi-systematic involvement of the coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Recent observations have revealed that, together with others, typical neurological manifestations are also associated with COVID-19 infection. In the first 2 years, children accounted for a few percent of cases, but with the emergence of the Omicron variant, the number of cases in the pediatric population has increased. It has been described that ~5% of the affected population suffered from severe neurological complications, such as seizure, coma, encephalitis, demyelinating disorders, and aseptic meningitis. Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system. Typically, it presents in childhood and occurs 1 or 2 weeks after infection or vaccination.Case presentationWe present the case of a 12-year-old boy who developed ADEM, 10 days after an asymptomatic SARS-CoV-2 infection. Neurological symptoms began with headache, fever, irritability, paraplegia, and loss of sensitivity from the T1 level. The diagnosis of ADEM was confirmed by the typical signs found on brain MRI, whereas spinal cord MRI showed signs of transverse myelitis. The cerebrospinal fluid (CSF) testing excluded infections and did not reveal oligoclonal antibody bands (anti-MOG-negative and anti-AQP-negative). High-dose steroids (30 mg/kg/day) and IVIG (2 g/kg) were administered to the patient without any clinical improvement. The patient received a cycle of plasma exchange therapy, followed by rituximab infusion, with partial improvement. After 3 months, the magnetic resonance imaging (MRI) results demonstrated radiological improvement in accordance with the ADEM diagnosis.ConclusionThis clinical case confirms that SARS-CoV-2 infections are increasingly implicated in severe neurological consequences in both adult and pediatric patients. While the most frequent complications that were reported in children included headache, altered mental status, and encephalopathy, ~5% of the individuals suffered from severe neurological complications, leading to lifelong sequelae. All physicians must be aware of these data and detect neurological signs of severe (or not) complications that require a specific follow-up and treatment.

Clinical characteristics of unvaccinated or incompletely vaccinated children with neurological manifestations due to SARS‐CoV‐2 Omicron infection

“…A total of 11 publications describing 46 pediatric patients with COVID‐19–related neurological manifestations were included in the systematic review 17,31–40 (Table 4). Among the 46 patients, 19 (41.3%) were female and 27 (58.7%) were males.…”

“…A total of 11 publications describing 46 pediatric patients with COVID-19-related neurological manifestations were included in the systematic review 17,[31][32][33][34][35][36][37][38][39][40] (Table 4). Among the 46 patients, Correlation analysis showed that higher CSF-to-blood IL-8 and CHI3L1 ratios were associated with longer length of hospitalization.…”

Pediatric acute disseminated encephalomyelitis following asymptomatic coronavirus disease 2019

“…The patient is currently progressing on a monophasic course without sequelae. Despite limited reports on ADEM associated with COVID-19 in children, several cases have indicated possible sequelae or relapse [15] , [20] . Prompt diagnosis and treatment initiation are desirable to avoid sequelae [2] , [10] .…”

Central nervous system complications in SARS-CoV-2-infected patients

“…A wide variety of neurological syndromes have been reported in COVID-19 cases, including encephalitis [ 9 , 30 – 33 ], encephalopathy, stroke, ADEM [ 14 ], reversible posterior leukoencephalopathy [ 34 – 36 ], optic neuritis [ 37 , 38 ], and epilepsy, among other. With reference to the standard case definitions for the association of COVID-19 with neurological disease [ 39 ], 7 of 12 patients (Patient 3, Patients 6–11) can be categorized as having probable SARS-CoV-2 encephalitis, 1 patient (Patient 1) can be described as having brain stem encephalitis probably associated with SARS-CoV-2 infection, 1 patient (Patient 5) can be described as having ADEM probably associated with SARS-CoV-2 infection, 1 patient (Patient 2) can be described as having MOG-antibody-associated optic neuritis probably associated with SARS-CoV-2 infection, 1 patient (Patient 4) can be described as having MS probably associated with SARS-CoV-2 infection, and the remaining patient (Patient 12) can be described as having tremor probably associated with SARS-CoV-2 infection.…”

“…The reported CNS complications related to COVID-19 mainly include encephalitis [ 9 – 11 ], acute myelitis [ 12 , 13 ], acute disseminated encephalomyelitis (ADEM) [ 14 ], cerebrovascular disease [ 15 , 16 ], seizure [ 7 , 17 ], and tremors, among others [ 18 , 19 ]. At present, the available information on CNS complications related to COVID-19 is mostly from case reports.…”