222 - Unmasking Acute Disseminated Encephalomyeloradiculitis in Post-Acute Rehabilitation: The Value of Interdisciplinary Evaluation

Acute Disseminated Encephalomyeloradiculitis

Case Description: 55-year-old male with recent aseptic meningitis secondary to varicella zoster infection presented 7 days later with flaccid paralysis and numbness without upper motor neuron signs. MRI spine showed cauda equina enhancement and lumbar puncture with lymphocytic pleocytosis and elevated protein concerning for acute inflammatory demyelinating polyradiculoneuropathy (AIDP). He was treated with IVIG and admitted to inpatient rehabilitation (IPR) though had difficulty tolerating therapy efforts due to fatigue. Post admission, he developed subjective difficulty swallowing and decreased intake. SLP noted new onset dysphagia and dysphonia. Repeat neurologic exam revealed perioral numbness, facial weakness, and intermittent dysconjugate gaze prompting acute care transfer. Repeat MRI brain and spine identified new peri-ventricular white matter lesions and diffuse spinal nerve root enhancement consistent with acute disseminated encephalomyeloradiculitis, treated with intravenous steroids and plasmapheresis. He returned to IPR with significant improvement in symptom load and therapy tolerance and discharged home with continued motor recovery.

Discussions:

Acute disseminated encephalomyelitis is primarily considered a disorder of the central nervous system (CNS) and less commonly has peripheral nervous system (PNS) involvement. PNS symptoms and imaging findings interestingly preceded CNS lesions in this patient’s presentation, leading to initial diagnosis of AIDP. Despite treatment and initial improvements, he developed unexplained symptoms that did not fit the working diagnosis. Symptoms were initially non-specific, but comprehensive evaluation by the interdisciplinary rehabilitation team helped identify new dysphagia and significantly reduced tongue movement. After detection of new CNS pathology and further treatment, he had improvement in fatigue, bulbar symptoms, and extremity strength, allowing improved tolerance of and participation in intensive therapies.

Conclusions:

Patients often undergo extensive diagnostic work-up prior to admission to post-acute rehabilitation, but it is important to monitor for new signs and symptoms that may point to an alternative diagnosis and treatment plan. Interdisciplinary collaboration is crucial for prompt identification of concerns.