Post-COVID Acute Demyelinating Encephalomyelitis in a Child: A Journey From Inflammation to Rehabilitation

Case Diagnosis: A 10 year-old previously healthy, developmentally appropriate male contracted COVID-19 and developed severe acute demyelinating encephalomyelitis (ADEM).

Case Description or Program Description: The patient presented with two weeks of cough, diffuse rash, and abdominal pain. Symptoms progressed to altered mental status and seizure. Imaging revealed hyperintensity in the right parietal and left frontoparietal white matter, as well as an expansile syrinx from C4 to T2. Labs showed positive COVID-19 testing and a negative meningitis/encephalitis panel. He declined further with brain herniation, requiring intubation and 21 days of external ventricular drain placement. He was treated with remdesivir, dexamethasone, IVIG, plasmapheresis, and rituximab and improved gradually.

When the patient was admitted to AIR, he was alert but predominantly voiced crying spells. He was tetraplegic and demonstrated poor cervical and truncal tone. He was dependent for all mobility and activities of daily living. The patient completed three months of AIR and progressed rapidly. By the end of AIR, he could ambulate 230 feet with a reverse walker at a supervision level, communicate his emotions, eat at a partial assistance level, and produce short sentences independently.

Setting: Acute inpatient rehabilitation (AIR)

Assessment/Results: With the recent COVID-19 pandemic, there has been a small, but increasing amount of literature depicting neurologic sequelae from COVID-19 infection. ADEM is a rare, immune-mediated process marked by demyelination and multifocal neurologic manifestations. Prior studies have demonstrated that the majority of children with ADEM have good functional recoveries.

Discussion (relevance): The incidence of ADEM after COVID-19 is very low; however, this is the first case report, to our knowledge, discussing the utility of multidisciplinary acute inpatient rehabilitation for this population.

Conclusions: ADEM can cause severe neurological deficits including tetraparesis, dysarthria, and cranial nerve palsies. Physiatrists should be aware that despite these severe neurological deficits, prognosis for children with ADEM are generally favorable, particularly when combined with a course of AIR.