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© Copyright 2018 American College of Physicians. All Rights Reserved. 190 North Independence Mall West, Philadelphia, PA 19106-1572
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All Authors: Aaron Sacheli, Raymond Bauer M.D. (St. John
Hospital & Medical Center, Detroit MI)
Acute disseminated encephalomyelitis (ADEM) describes a
demyelinating condition of the central nervous system. It is known
that 75% of cases arise from post-infectious and post-immunization
events with annual incidence rates ranging from 0.4 to 0.8 per
100,000. While rare, it remains an important clinical consideration
in patients with neurologic symptoms in the context of recent
A fifty year-old, Caucasian male, presented with a course of
progressive, focal, left-sided neurologic deficits within
twenty-four hours after influenza vaccination. The patient has a
non-contributory past medical history. Physical examination
demonstrated no significant findings, except for definitive left
sided weakness (3/5) and hypertonicity. Sensation to pain,
temperature and vibration was intact.
The full evaluative course initially focused on a working
diagnosis of acute stroke. Chest X-ray, computed tomography (CT) of
the head, and CT angiography of the head and neck were all
unremarkable. Carotid duplex demonstrated carotid stenosis less
than 40% on the right and the left. Subsequent magnetic resonance
imaging (MRI) of the brain showed scattered non-specific foci of
white matter gliosis, from possible arteriopathy or venopathy. MRI
of the cervical, thoracic and lumbar spine proved benign.
Cerebrospinal fluid (CSF) sample was completely normal by
laboratory evaluation, and gram stain was negative with no growth
on culture after seven days. Additionally, cytological analysis
showed no evidence of malignancy, and there were no oligoclonal
bands. Cardiology work-up, including an EKG and an echocardiogram,
was normal. Post-vaccination ADEM appeared to best encompass this
patient's clinical picture.
A five day course of, twice daily, intravenous methylprednisone
(500mg) was prescribed, followed by a 12 day tapered course of,
once daily, oral prednisone (20mg). Additionally, the patient was
referred for comprehensive inpatient rehabilitation. The 12 day
course of rehabilitation treatment consisted of intense Activities
of Daily Living, gait, and transfer training, as well as
strengthening exercises. His Functional Independence Measure score
improved from 74 to 106.
Few case reports of ADEM have been noted following influenza
vaccination, but only in the young and in the elderly. This report,
to our knowledge, in addition to being a rare clinical occurrence,
is the first to describe ADEM within twenty-four hours of influenza
vaccination and the first in a middle aged patient. Though
uncommon, ADEM may be encountered at both the in-patient and
primary care level given the wide contingent of influenza
vaccinated patients. Prompt medical management and plans for
comprehensive and focused rehabilitation are pivotal to favourable
clinical outcomes in these patients.
June 2014 Issue of IMpact