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Acute Disseminated Encephalomyelitis Or Multiple Sclerosis: Can the Initial Presentation Help in Establishing a Correct Diagnosi

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Acute Disseminated Encephalomyelitis Or Multiple Sclerosis: Can the Initial Presentation Help in Establishing a Correct Diagnosi 636 REVIEW Acute disseminated encephalomyelitis or multiple sclerosis: can the initial presentation help in establishing a correct Arch Dis Child: first published as on 20 May 2005. Downloaded from diagnosis? R C Dale, J A Branson ............................................................................................................................... Arch Dis Child 2005;90:636–639. doi: 10.1136/adc.2004.062935 The differential diagnosis of CNS white matter disease is and MS cases must manifest disseminated disease of the CNS (more than one clinical or broad, and can be divided into vascular, metabolic, radiological site). Diseases isolated to specific infective, or inflammatory aetiologies. Isolated areas of the CNS (isolated optic neuritis, trans- inflammatory disorders of the CNS are often associated verse myelitis, and brain stem dysfunction) are considered distinct from both ADEM and MS with demyelination, and the two terms (inflammatory and (clinically and prognostically), and will not be demyelinating) are often used in conjunction. When the discussed in this review.89 disease is monophasic, the term acute disseminated 1 DEMOGRAPHICS encephalomyelitis (ADEM) is used. ADEM typically occurs Monophasic ADEM is more common in children, as a post-infectious phenomenon, and by definition, must whereas MS is more common in adults. Between be an isolated (monophasic) episode. If a relapse occurs 2.7% and 4.4% of MS presentations occur in children less than 16 years of age.8 Mikaeloff et al shortly after the ADEM presentation in association with a showed a mean age of 7.1 years and 12.0 years in further infection or steroid withdrawal, the term MDEM paediatric ADEM and MS patients respectively.8 (multiphasic disseminated encephalomyelitis) is used. Most reports of ADEM have described a peak incidence in children of 3–10 years.3–6 An When there are relapses or progressive disease, the term adolescent presenting with a first demyelinating multiple sclerosis (MS) is used (for full recommended event is more likely to develop multiple sclerosis http://adc.bmj.com/ diagnostic criteria for multiple sclerosis refer to McDonald than a younger child.38 Most series of ADEM 2 have failed to show a sex predominance, and colleagues ). although some series show a mild male pre- ........................................................................... dominance.358 By contrast, females are more predisposed to develop multiple sclerosis, parti- 8 he diagnostic differentiation between acute cularly in adolescence and adulthood. disseminated encephalomyelitis (ADEM) on September 30, 2021 by guest. Protected copyright. Tand multiple sclerosis (MS) is important PRECIPITATING INFECTION AND mainly for prognostic reasons. Children with SEASONALITY ADEM are generally expected to do well, whereas As would be expected from an infection children with MS are more likely to develop mediated syndrome, ADEM most commonly significant disability. The ability to reduce MS presents during winter and spring.34 Between disease progression with immunomodulatory 51% and 74% of ADEM patients have a history of drugs further emphasises the importance of a a precipitating infection with a mean latency of prompt and accurate diagnosis. Over the last five approximately two weeks.3–6 8 A large number of years, there have been a number of large series infections may precipitate ADEM, although reporting the clinical features of paediatric isolation of a specific agent is uncommon (classic ADEM, MS, and the differences between infectious precipitants include measles, Epstein- these.3–8 A large follow up series of children with Barr virus, mycoplasma, and group A strepto- 110 a first episode of central nervous system (CNS) coccus). Although infections may precipitate inflammatory demyelination showed a much an MS relapse, the association with infections higher rate of progression to multiple sclerosis and seasonality is less pronounced (only 16% of than previously reported.8 The clinical features of patients have an infection in the preceding See end of article for month8). authors’ affiliations these treatable disorders are therefore the subject ....................... of this review. It must be stated from the outset that the clinical and laboratory differences NEUROLOGICAL SYMPTOMS AND SIGNS Correspondence to: Patients with ADEM are more likely to present Dr R C Dale, between ADEM and MS are trends only, and Neuroimmunology do not provide rigid diagnostic criteria. with encephalopathy and may be initially diag- Laboratory, 9th Floor, nosed as having viral encephalitis.38 ADEM Institute of Neurology, patients commonly have headache, vomiting, Queen Square, London THE DIAGNOSTIC DILEMMA WC1N 3BG, UK; r.dale@ The research purpose of this review is to address ion.ucl.ac.uk Abbreviations: ADEM, acute disseminated the diagnostic dilemma presented in fig 1. Are encephalomyelitis; CNS, central nervous system; MDEM, Accepted 28 October 2004 ADEM and MS distinct clinical disorders, or part multiphasic disseminated encephalomyelitis; MS, multiple ....................... of a disease spectrum? By definition, both ADEM sclerosis; ON, optic neuritis www.archdischild.com ADEM and MS 637 40–95% of MS patients, but only 0–29% of ADEM patients.3568 Indeed, some authorities would seriously question the diagnosis of MS if there were not intrathecal ADEM MS OR ADEM MS synthesis of oligoclonal IgG. MAGNETIC RESONANCE NEUROIMAGING Arch Dis Child: first published as on 20 May 2005. Downloaded from MRI is an essential part of the investigation of ADEM and Figure 1 Diagnostic dilemma: are ADEM and MS separate clinical MS. Both ADEM and MS show disseminated inflammatory entities or part of the same demyelinating spectrum? lesions throughout the CNS (although predominantly in the white matter). Occasionally, large mass-like lesions occur drowsiness, and meningism. These symptoms are uncommon and may require a biopsy.5614 A number of studies have in MS.368 Seizures occur in 13–35% of ADEM patients, reported imaging differences between childhood ADEM and although they are seldom as problematic as those seen in MS. The lesions in ADEM often have poorly defined viral encephalitis, which is more likely to involve cortical grey margins,3–6 15 whereas MS lesions have well defined ‘‘plaque- matter.3–6 By contrast, seizures are considered rare in multiple like’’ margins.16 There are also differences in the lesion sites. sclerosis.11 Periaqueductal, corpus callosum, and periventricular white As both ADEM and MS are disseminated disorders of the matter lesions are characteristic of MS.315 By contrast, in CNS, a broad range of neurological signs is possible. ADEM the lesions tend to be in the deeper white matter with Pyramidal, cerebellar, and brain stem signs are common in periventricular sparing (only 29–60% of ADEM patients have both disorders.38Encephalopathy with depressed conscious- periventricular lesions) (fig 2).346 When the spinal cord is ness and altered sensorium is more common in ADEM (45– involved in ADEM, the lesion is typically large, swollen, and 75%)3–6 8 than in MS (13–15%).38Optic neuritis (ON) occurs thoracic. The spinal cord lesions in MS are typically smaller, in both ADEM and MS. ON is frequently bilateral in ADEM, more discrete, and cervical. In addition, although the white whereas it is typically unilateral in MS.131213 Morrissey’s matter is classically involved in both disorders, the grey study also noted the importance of considering Leber’s matter (both cortical and deep grey/basal ganglia) is 3–5 15 17 18 hereditary optic neuropathy (a mitochondrial mutation) in frequently involved in ADEM (in contrast to MS). children presenting with bilateral optic neuritis/neuropathy.13 Post-streptococcal ADEM shows particular predisposition to 19 As ADEM tends to be more florid, there are frequently basal ganglia lesions. A recent MRI study of 116 children multiple symptoms and signs (polysymptomatic presenta- with a first episode of inflammatory demyelination showed tion), whereas symptoms and signs are commonly isolated that perpendicular corpus callosum lesions and the sole (monosymptomatic) in MS.38 presence of well defined lesions were the most specific predictive factors for relapse (although they had a low sensitivity).20 BLOOD AND CSF FEATURES Follow up MRI is useful in ADEM/MS differentiation. As http://adc.bmj.com/ In keeping with an explosive post-infectious phenomenon, would be expected, new lesions should not occur in ADEM patients with ADEM frequently have raised inflammatory (0–9% of ADEM patients have new lesions on follow markers (white cell count, erythrocyte sedimentation rate) up).3 5 21 22 The original lesions in ADEM completely resolve and lymphopenia.346In contrast, in MS these are frequently in 27–55% of ADEM patients, although more typically (45– normal.3 The CSF more commonly shows an increased 64%) the lesions only partially resolve.32021By contrast, new protein and cell count (lymphocytosis) in ADEM, although lesions in MS are anticipated.17 The timing of repeat scanning normal and abnormal CSF findings occur in both ADEM and is important, as too hasty a repeat scan may cause confusion on September 30, 2021 by guest. Protected copyright. MS.3–6 8 One of the most discriminating CSF findings is the if the patient is still in the acute/subacute phase. A lag time of presence of intrathecal synthesis of oligoclonal bands six months after presentation would be appropriate for repeat (oligoclonal IgG in CSF but not in serum), which occurs in scanning (when clinically
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