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Washington University Experience | MYELIN (IMMUNE-MEDIATED) | ADEM | 4A0 Case 4 History
Case 4 History ---- The patient was a 6-1/2-year-old boy with no significant past medical history who presented three weeks prior to admission when he began to develop a frontal headache, emesis, altered speech pattern, right facial droop, decreased use and increased clumsiness of his right arm and leg. MRI of the head revealed multiple lesions in several vascular territories thought to represent infarcts. A repeat MRI performed at our hospital shortly thereafter confirmed a previously seen basal ganglia lesion but also detected multiple new cerebellar lesions which were thought to represent multiple infarcts. However, an exhaustive workup failed to find any support for an ischemic diagnosis and the absence of diffusion-weighted MRI lesions suggested that the lesions were not infarcts. CSF analysis showed 28 total cells with 13 white blood cells (65% lymphs and 17% monos), glucose 56, protein of 39, and normal lactate and pyruvate levels. An angiogram failed to detect vasculitis. The decision was made to place him on low dose aspirin for stroke prophylaxis and to follow-up with an MRI in two months to see whether these lesions had evolved. He was discharged home in good condition with tentative diagnosis of multiple cerebrovascular accidents. At followup examination 1 month later he had progression of the left cerebellar lesion, which enhanced on CT and MRI scan, and was growing. There was mass effect, and the patient appeared to be symptomatic from this lesion with ataxia. As a result he was biopsied. Following a brain biopsy and treatment there was reported contact with the patient 19 years later but without any details.
