Acute disseminated encephalomyelitis after mixed malaria infection (plasmodium falciparum and plasmodium vivax) with MRI closely simulating multiple sclerosis

Abstract

Introduction: Acute disseminated encephalomyelitis (ADEM) is a monophasic, inflammatory, immune-mediated disorder of the central nervous system. It is particularly difficult to distinguish between ADEM and an initial attack of multiple sclerosis (MS) clinically and based on magnetic resonance imaging (MRI) or cerebrospinal fluid. ADEM is quite rare after malaria infection. Our patient, although diagnosed provisionally of ADEM after mixed malaria infection, had neuroimaging closely simulating MS. CASE REPORT: We report a case of a woman with an adult type 2 diabetes presenting with fever and diagnosed by antigen assay to be suffering from mixed malaria infection (Plasmodium falciparum, Plasmodium vivax). While recovering with artesunate and doxycycline therapy, she developed acute onset bladder retention followed by paraparesis. On examination she had evidence of Upper Motor Neuron (UMN) signs in all the 4 limbs along with truncal sensory loss. Discussion: Her MRI of spine showed T2 hyperintensities suggestive of resolving myelitis. MRI of the brain showed multifocal and confluent areas of demyelination mostly involving the corpus callosum and periventricular region. Lesions, particularly the callosal ones, closely simulated MS. In accordance with the McDonald Criteria and Barkhofs MRI Criteria, this patient did not fit into the diagnosis of MS. Our provisional diagnosis was ADEM. © 2011 by Lippincott Williams & Wilkins.