731 - When a Common Infection Meets the Brain: A Case of Pediatric Mycoplasma-Associated Para-infectious Atypical Acute Disseminated Encephalomyelitis in the Setting of Acute Inpatient Rehabilitation

Mycoplasma-associated para-infectious atypical acute disseminated encephalomyelitis 

Case Description:

An 8-year-old female presented with fever, cough, congestion, and fatigue that progressed to decreased arousal, loss of purposeful movement, and lack of response to pain with an observed GCS of 8-9. Brain MRI showed diffuse septic emboli with extensive encephalomyelitis with multifocal cytotoxic edema, and spine MRI showed hyperintense signal abnormalities along the cord from C6 through conus. She underwent extensive infectious and immunologic evaluation with results consistent with mycoplasma-associated para-infectious atypical ADEM. She was initially treated with high-dose IV methylprednisolone without response, so she was started on plasma exchange (PLEX) for 5 treatments with improvement in neurologic symptoms.  After treatment and an 11-day stay in inpatient rehabilitation, the patient showed functional improvements in gross motor skills and ADLs. At the 6-month follow-up appointment, the patient is back to baseline with the exception of mild foot intrinsic weakness, which does not seem to impact daily functioning. 

Discussions:

Neurological complications of Mycoplasma pneumoniae infection have been reported in the limited literature as uncommon. Studies show that an initial respiratory prodrome precedes the development of CNS symptoms, which can result in deficits in executive function, learning, memory, motor function, and behavioral abnormalities. Immunotherapies such as IVIG and corticosteroids are gold-standard treatments for this condition. Plasma exchange is an uncommon, second-line therapy and is reserved for severe cases that do not respond to high-dose intravenous corticosteroids. During inpatient stay, the patient exhibited significant improvements in her self-care, dressing, and mobility WeeFIM scores from admission to discharge. 

Conclusions:

This case highlights how rare cases of ADEM can be unresponsive to first-line treatment and that the combination of PLEX and inpatient rehabilitation can lead to favorable long-term outcomes.