Case Presentation: An eighteen-year-old woman presents with progressively worsening weakness in her legs as well as numbness throughout her body. She also endorsed rhinorrhea, nasal congestion, abdominal discomfort, nausea, vomiting and decreased urine output. Her past medical history included depression and asthma. She received a flu vaccine 30 days prior to symptom onset and denied recent travel or bug bites. She endorsed marijuana use.
On presentation, patient was hemodynamically stable and afebrile. Initial neurological exam revealed decreased sensation to sharp touch bilaterally in lower extremities and bilateral hyperreflexia in both lower extremities; strength was intact at this time. Patient was found to be retaining 1300mL of urine which was emptied with resolution of her abdominal discomfort and an indwelling catheter was placed. Laboratory studies were significant for a white blood cell count of 13.7 with a normal hemoglobin; chemistries and liver function tests were within normal limits. Respiratory pathogen panel was positive for enterovirus and rhinovirus. Lumbar puncture was performed and showed a glucose of 50, protein of 54, red blood cell count of 114 and 24 nucleated cells. Brain CT was unremarkable and lumbar MRI was initially read as normal.
Discussion: This patient was admitted to internal medicine and started on broad spectrum antibiotics and antivirals for meningitis. Throughout the first 24 hours of admission, the patient’s exam worsened as she developed upper and lower extremity weakness to the point that should could not ambulate. Additionally, she developed eye pain with extraocular movements, upper extremity dysmetria bilaterally, and right greater than left pronator drift. Due to her worsening neurological status, an MRI brain and spine were completed revealing multiple non-enhancing supratentorial lesions with diffuse abnormal cord signal and expansion of the conus medullaris. Patient was started on high-dose intravenous steroids. On her second hospital day, her symptoms began to improve. By hospital day three her strength had fully returned. This patient’s ability to void independently was the last function to return, but she recovered and was discharged without persistent neurological deficits.
This patient’s presentation and imaging findings are suggestive of acute disseminated encephalomyelitis (ADEM). Patients usually present with rapid-onset neurological deficits requiring hospitalization. Neurological changes can include weakness, sensory deficits, dysarthria, vision changes, urinary retention and seizures. Altered mentation can also be associated. This constellation of neurological symptoms is thought to be caused by autoinflammation likely triggered by a viral illness. Treatment is five days of high-dose intravenous steroids. Steroids do not affect severity of illness progression, but aid speed of recovery and return of function. Presentation is usually monophasic, but recurrences have been observed. Also, it is possible that this event can be the first presentation of more chronic demyelinating disease such as multiple sclerosis (MS). Absence of oligoclonal bands on lumbar puncture makes MS less likely in this case.
Conclusions: Neuromuscular diseases can present in varying ways and are often managed in the inpatient medicine setting. It is essential for hospitalists to be able identify when additional imaging is needed and when to begin initial treatment.