Case Presentation:

A 5–year–old white female presented to the ED with 3 day history of vomiting. She has had two week history of upper respiratory symptoms prior to the onset of vomiting. The emesis was non–bilious and non–bloody. There was no diarrhea. ROS was noted for fever, cough, vomiting, and headaches. CXR was negative for airspace disease. WBC was 23,000 with a left shift. After a blood culture was collected, she was given an IV dose of ceftriaxone. She also received a NS bolus. Admission was requested due to dehydration. In addition, her mycoplasma screen was positive. She was treated with Azithromycin. During the hospitalization, she continued to complain of headaches. The severity of the headaches intensified to the point that she required IV morphine for pain relief. There was a strong family history of migraines, and initially it was thought that the headaches were the manifestation of migraine headaches. Her neurological examination remained normal. A pediatric neurology consult was obtained due to the severity and frequency of the headaches. A brain MRI showed multiple white matter lesions in the subcortical white matter, involving the frontal, parietal, and occipital lobes. Findings were consistent with acute disseminated encephalomyelitis (ADEM). A lumbar puncture showed CSF protein level of 41 mg/dL and glucose level of 49 mg/dL. The CSF WBC was 48 cells/uL, and RBC was 18/MM3. CSF oligoclonal bands were negative. The patient received high dose corticosteroid therapy. After 3 days, there was resolution of her headaches. She was discharged home on a steroid taper with a pediatric neurology follow–up.

Discussion:

Acute disseminated encephalomyelitis (ADEM) is a non–vasculitic inflammatory demyelinating disorder of the central nervous system (CNS). It is characterized by diffuse neurologic signs and symptoms, including encephalopathy, hemiperesis, weakness, ataxia, and headaches. On neuro–imaging, there is evidence of multifocal lesions of demyelination. Prognosis is generally excellent with only 1.5% mortality due to ADEM related complications.

Conclusions:

This case highligted an usual cause of headache in a child. ADEM is a rare clinical finding in children. The purpose of this case presentation is to increase the general knowledge of this disease entity and to provide current literature review.

Figure 1Brain MRI showing white multiple white lesions in the subcorticalwhite matter.