Acute Disseminated Encephalomyelitis With Brain Abscess in a 3-Year-Old Immunocompetent Child: A Case Report

Abstract

Acute disseminated encephalomyelitis (ADEM) is a monophasic immune-mediated inflammatory demyelinating condition that predominately affects the white matter of the brain and spinal cord. On magnetic resonance imaging (MRI), lesions are usually diffuse, poorly demarcated, and demonstrate regions of high signal on T2 with surrounding edema. On the other hand, intracranial abscesses are uncommon, serious and life-threatening infections. On MRI, restricted water diffusion, in ring-enhancing lesions, is typical of brain abscesses. We report a challenging case of a 3-year-old boy presenting with fever, severe headache, somnolence and neck stiffness. The cerebrospinal fluid (CSF) showed high white blood cell count and the brain MRI showed two lesions evoking abscesses with multiple areas of vasogenic edema. Six days later and due to the persistence of the somnolence with a gait disturbance despite antibiotic therapy, a follow-up MRI showed a better delineation of the vasogenic edema that now evokes ADEM lesions with regression of the two lesions evoking abscesses. Diagnostic considerations were brainstem abscesses or ADEM or an association between them. However, no association between these two entities has been reported in the literature. Because first MRI lesions were typical of abscesses, the diagnosis of an association between brain abscesses and ADEM was retained. The patient was treated with high doses of steroids that drastically and promptly improved his condition and the antibiotic therapy was continued for 4 weeks despite the absence of bacterial growth on CSF culture. In conclusion, we report here a first case of an association between brain abscesses and ADEM in a child with a good evolution after treatment. The differential diagnosis could be atypical MRI images of ADEM that resembled abscesses.

Int J Clin Pediatr. 2019;8(2):41-44
doi: https://doi.org/10.14740/ijcp339