Objective:

To describe a unique case of acute disseminated encephalomyelitis (ADEM) in a patient post-COVID-19 infection who was initially misdiagnosed as having an ischemic stroke.

Background:

ADEM is a condition involving acute, autoimmune demyelination of the brain and spinal cord seen more commonly in pediatric populations. The relationship of COVID-19 to ADEM is not well understood as there are few reported cases.

Design/Methods:

NA

Results:

A 63-year-old female Nepalese immigrant presented with a seven-day history of right sided weakness and expressive aphasia. She was initially misdiagnosed with an ischemic stroke. However, her weakness and aphasia progressively worsened. The patient’s daughter tested positive for COVID-19 approximately six weeks prior, and the patient was also symptomatic during that time. The neurologic examination was remarkable for right hemiparesis, a right-sided Babinski sign, decreased sensation in her right hemibody, and expressive aphasia. Myelin oligodendrocyte glycoprotein (MOG) IgG titers were low-positive. Cerebrospinal fluid was remarkable for mildly elevated protein. A magnetic resonance imaging of the brain with contrast showed multiple enhancing bilateral intraparenchymal lesions with peripheral diffusion restriction and central T2 shine through. Histopathology of a brain biopsy revealed a macrophage-rich lesion associated with myelin loss with axonal preservation. The patient was started on high-dose methylprednisolone and plasmapheresis for fourteen days with clinical improvement.

Conclusions:

ADEM should be considered as a potential diagnosis in patients with recent COVID-19 infection presenting with focal neurologic symptoms. Early suspicion and diagnostic workup of a post-viral autoimmune process is important for initiating immunosuppressive treatments promptly, which leads to better clinical outcomes. Attention must also be brought to health disparities in treatment of immigrants.