462 - An Atypical Presentation of Parkinsonian Symptoms in an Adult with Acute Disseminated Encephalomyelitis

Case Diagnosis: Acute Disseminated Encephalomyelitis (ADEM)

Case Description: A 66-year-old male with history of familial Mediterranean fever and a recent respiratory infection presented with unresponsiveness, fever, and rash. He was admitted to the ICU and treated for aspiration pneumonia with azithromycin and steroids. Days later, he was readmitted with generalized weakness and declining mental status. He had a shuffling gait, resting tremor, cogwheel rigidity, flat affect, and abulia. His workup was notable for new generalized white matter changes with a predominance for periventricular regions and the basal ganglia on brain MRI and elevated protein concentration in cerebrospinal fluid samples. He ultimately underwent brain biopsy which found macrophage-rich patchy regions of demyelination, consistent with ADEM. He was initially treated with intravenous immunoglobulins, but treatment was limited by a respiratory infection. Subsequently, he underwent five rounds of plasmapheresis. Once admitted to inpatient rehabilitation, he was trialed on carbidopa-levodopa and responded favorably with significant functional improvement in initiation and rigidity.

Discussions: ADEM is an inflammatory disorder of the central nervous system that presents as an acute encephalopathy with multifocal neurologic symptoms often following an infection. Although parkinsonian features have been reported as rare manifestations of other demyelinating disorders such as multiple sclerosis, this is an atypical presentation of ADEM. Similar to other conditions which present with parkinsonian features, the patient had rapid improvement with dopaminergic augmentation.

Conclusions: Although rare in ADEM, neurological rehabilitation patients with multiple parkinsonian features have the potential to respond favorably to dopaminergic and as such medication trials should be considered.