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Post-COVID-19 Acute Disseminated Encephalomyelitis in a 17-Month-Old

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Post-COVID-19 Acute Disseminated Encephalomyelitis in a 17-Month-Old Prepublication Release Post-COVID-19 Acute Disseminated Encephalomyelitis in a 17-Month-Old Loren A. McLendon, MD, Chethan K. Rao, DO, MS, Cintia Carla Da Hora, MD, Florinda Islamovic, MD, Fernando N. Galan, MD DOI: 10.1542/peds.2020-049678 Journal: Pediatrics Article Type: Case Report Citation: McLendon LA, Rao CK, Da Hora CC, Islamovic F, Galan FN. Post-COVID-19 acute disseminated encephalomyelitis in a 17-month-old. Pediatrics. 2021; doi: 10.1542/peds.2020- 049678 This is a prepublication version of an article that has undergone peer review and been accepted for publication but is not the final version of record. This paper may be cited using the DOI and date of access. This paper may contain information that has errors in facts, figures, and statements, and will be corrected in the final published version. The journal is providing an early version of this article to expedite access to this information. The American Academy of Pediatrics, the editors, and authors are not responsible for inaccurate information and data described in this version. Downloaded from©202 www.aappublications.org/news1 American Academy by of guest Pediatrics on September 27, 2021 Prepublication Release Post-COVID-19 Acute Disseminated Encephalomyelitis in a 17-month-old a,b Loren A. McLendon, MD, a,b Chethan K. Rao, DO, MS, c Cintia Carla Da Hora, MD, c Florinda Islamovic, MD, b Fernando N. Galan, MD Affiliations: a Mayo Clinic College of Medical Science Florida, Division of Child and Adolescent Neurology, Jacksonville, Florida b Nemours Children Specialty Clinic, Division of Neurology, Jacksonville, Florida c University of Florida College of Medicine Jacksonville, Division of Pediatrics, Jacksonville, Florida Corresponding Author: Fernando N. Galan, MD Division of Child Neurology 807 Children’s Way Jacksonville, Florida 32207 [email protected] Conflict of Interest Disclosures: The authors have indicated they have no conflicts of interest relevant to this article to disclose. Key Words: ADEM, COVID-19, encephalitis, pediatrics, SARS-CoV2 Abbreviations: Acute disseminated encephalomyelitis (ADEM), antinuclear antibody (ANA), Aquaporin 4 antibodies (NMO Ab), Central nervous system (CNS), Cerebral spinal fluid (CSF), Electroencephalography (EEG), erythrocyte sedimentation rate (ESR), intravenous immunoglobin (IVIG), lactate dehydrogenase (LDH), magnetic resonance imaging (MRI), myelin oligodendrocyte glycoprotein antibodies (MOG Ab), pediatric intensive care unit (PICU), polymerase chain reaction (PCR), thyroid peroxidase antibodies (TPO) Downloaded from©202 www.aappublications.org/news1 American Academy by of guest Pediatrics on September 27, 2021 Prepublication Release Funding/Support: No funding was secured for this study. Table of Contents Summary: Case description of acute demyelinating encephalomyelitis (ADEM) in a toddler following SARS-CoV-2 infection and response to standard immunotherapy. Contributors’ Statements: Dr. McLendon performed data acquisition, drafted the initial manuscript, revising the figure, and critically reviewed the manuscript. Dr. Rao performed data acquisition, contributed to drafting of the initial manuscript and drafting of Figure 1, and critically reviewed the manuscript. Drs. Da Hora and Islamovic performed data acquisition and contributed to drafting of the initial manuscript. Dr. Galan conceptualized the study, supervised data collection, and critically reviewed the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Downloaded from©202 www.aappublications.org/news1 American Academy by of guest Pediatrics on September 27, 2021 Prepublication Release Abstract: Neurological manifestations of SARS-CoV-2 infection in pediatric patients have been reported in the acute and post-infectious stages of COVID-19 disease. Acute disseminated encephalomyelitis (ADEM) typically presents in children following a viral illness at a mean age of three to seven years. Sixty to ninety percent of literature-reported pediatric patients with ADEM have minimal to no neurologic deficits at long-term follow-up. We present a 17-month- old developmentally-typical female with parental complaints of irritability, upper extremity weakness, and gait disturbance. She presented to the hospital afebrile and irritable with subtle right-sided nasolabial fold flattening, significant neck stiffness, left upper extremity rigidity, right upper extremity paresis, bilateral lower extremity hyperreflexia, and truncal ataxia. During her hospital course, she became somnolent with autonomic instability and was transferred to intensive care. Contrasted brain magnetic resonance imaging (MRI) revealed diffuse patchy T2 hyperintensities without evidence of contrast enhancement. Nasopharyngeal swab SARS-CoV-2 polymerase chain reaction (PCR) and serum antibody testing were both positive. Cerebral spinal fluid (CSF) analysis was unremarkable. Respiratory viral panel, autoimmune encephalitis and demyelinating disorders panel were negative. She was started on high dose methylprednisolone and intravenous immunoglobulin (IVIG) with improvement in mental status, focal deficits, and ambulation. Following hospital discharge, she received inpatient rehabilitation for two weeks and at two month follow-up had full neurologic recovery. We report the youngest case of post- infectious ADEM due to SARS-CoV-2 in a toddler. Early recognition of autoimmune and inflammatory complications of SARS-CoV-2 is vital for early aggressive immunomodulatory treatment and consequently improved morbidity in these patients. Downloaded from©202 www.aappublications.org/news1 American Academy by of guest Pediatrics on September 27, 2021 Prepublication Release Introduction: COVID-19 caused by the novel coronavirus SARS-CoV-2 disproportionately spares pediatric populations, representing less than two percent of reported cases in multinational studies.1 Up to 35% of infected children are asymptomatic, and the remainder often have mild symptoms such as fever, cough, and headache. However, severe complications related to COVID-19 in children have been reported including respiratory failure, multisystem inflammatory syndrome, and a variety of neurological sequelae.2 Individual cases of seizure, cerebrovascular infarction, encephalitis, and myelitis in children with active or recent COVID-19 infection have been reported.2,3 Acute disseminated encephalomyelitis (ADEM), or post-infectious encephalomyelitis, is an immune-mediated process marked by demyelination and multifocal neurological manifestations.4-6 ADEM is typically preceded by symptoms of fever, malaise, vomiting, and/or headaches. Neurological symptoms are multifocal and correlate with radiologic lesions in the brain and/or spinal cord; clinically presenting as ataxia, encephalopathy, hemiplegia, hemiparesthesias, visual changes, seizures, or cranial nerve palsies.4,5,7,8 This neurological decline occurs rapidly within days to weeks after the prodromal illness; symptoms in the majority of patients do not progress beyond three months.9 We present a case of ADEM secondary to COVID-19 in a 17-month-old girl who fared well with early and aggressive immunomodulating therapy which included high-dose corticosteroids and IVIG treatments. Downloaded from©202 www.aappublications.org/news1 American Academy by of guest Pediatrics on September 27, 2021 Prepublication Release Case: A 17-month-old African-American, non-Hispanic, previously-healthy, and developmentally- typical female presented to the emergency department with fatigue, progressively worsening weakness, and unsteady gait. She had five days of fever, approximately 13 days prior to presentation with a maximum temperature of 38.9 degrees Celsius without associated upper respiratory or gastrointestinal symptoms. After fever resolution, her parents noticed progressive fatigue, decreased communication, difficulty feeding herself, walking, and sitting without support. She presented to the hospital with parental complaints symptoms of irritability, weakness of upper extremities, and gait disturbance. She was found to be afebrile but irritable with subtle right-sided nasolabial fold flattening, significant neck stiffness with positive Brudzinski’s sign, left upper extremity rigidity, right upper extremity paresis, bilateral lower extremity hyperreflexia, and truncal ataxia. Initial evaluation included an electrocardiogram with normal sinus rhythm, possible right atrium enlargement, and left ventricular hypertrophy. Transthoracic echocardiogram performed in the Pediatric Intensive Care Unit (PICU) was normal. Laboratory evaluation noted elevated inflammatory markers including an erythrocyte sedimentation rate (ESR) of 25 mm/hr which increased to 40 mm/hr within two days and lactate dehydrogenase (LDH) of 406 IU/L. Normal serum studies included complete blood count, comprehensive metabolic panels, PT/INR, PTT, ferritin, D-dimer, BNP, troponins, ammonia levels, and creatine kinase. MRI of the brain with and without gadolinium contrast showed multifocal hyperintense T2 FLAIR signals in bilateral subcortical and periventricular white matter without contrast enhancement (Figure 1). Downloaded from©202 www.aappublications.org/news1 American Academy by of guest Pediatrics on September 27, 2021 Prepublication Release MRI of the whole spine without contrast was unremarkable. CSF and serum studies were performed prior to the initiation of high-dose methylprednisolone. CSF analysis revealed mild pleocytosis with lymphocytic predominance;
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