A previously healthy 25-year-old male patient reported a five-day history of cough, odynophagia, fever, myalgia and chills.
After two days without symptoms, the fever reappeared (38°C) and developed diplopia in the right eye accompanied by ataxia, mild dysphagia, paresis in the right upper limb and progressive dyspnea.
She was admitted to the emergency department with rapid intubation and connection to invasive mechanical ventilation (IMV).
The patient's medical history revealed that she had received the complementary anticancer vaccine one month prior to the onset of symptoms.
She had no relevant family history, contacts with toxics or animals, sexually transmitted diseases or risk behaviors for them, exposure to a rural environment, travel outside the country, or symptoms suggestive of mesenchymal diseases.
Physical examination revealed obtundation, vertical nystagmus, paresis of the VI and VII cranial nerves and right brachial hemiparesis.
There was no elevation in inflammatory parameters and cerebrospinal fluid (CSF) showed 8 cells/mm3, glucorrachy 77 mg/dL, protein binding 38 mg/dL, negative adenosine tyrosine test Chinese ink.
No oligoclonal bands or intrathecal antibodies were detected.
Computed axial tomography (CAT) of the brain without contrast showed no abnormalities.
The first brain magnetic resonance imaging (MRI) showed in T2, Flair and Diffusion sequences multiple hyper-intense foci in the area between the right medulla spinal cord and the right parietal cortex-convex regions.
All of them were impregnated with gadolinium (Gd), translating acute inflammatory activity.
Differential diagnoses included acute disseminated encephalomyelitis, multiple vasculitis and septic embolism.
The angioresonance was normal, ruling out an acute stroke.
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Empirical treatment was initiated with ceftriaxone IV 2 g every 12 h, ampicillin IV 3 g every 6 h, viridase iv 10 mg/kg/doses every 8 h and dexamethasone IV.
During the first 72 h an extensive etiological study was performed: syphilis serology, HIV, Epstein (VEB) virus, cytomegalovirus (CMV), Mycoplasma pneumoniae, Brucella spp.
In addition to the hemocultives, the toxicological examination for different compounds (cocaine, cannabinoids, anaphylaxis and metanific), antinuclear antibodies and anti-neutrophil cytoplasmic antibodies were also negative.
Thyroid tests and immunoglobulin counts were within normal ranges and there were no changes in the CT scan of the chest, abdomen and pelvis, nor were vegetations evident in the transesophageal echocardiogram.
In parallel, the CSF specific study showed no bacterial growth and was negative for herpes simplex virus 1 and 2 (HSV 1 and 2), varicella zoster (VZV), CMV and EBV by PCR.
Establishment of malignancy virus 3 was detected by immunofluorescence using a nasopharyngeal sample.
In contrast, there was no evidence of other respiratory viruses tested (degree of respiratory distress syndrome A and B, voiding dysfunction syndrome, dementia), adenovirus 1, and human metapneumovirus).
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After excluding viral and bacterial meningoencephalitis, it was decided to suspend antibacterial and antiviral therapy 72 h after the beginning.
In this scenario, considering the progressive neurological deterioration and MRI findings, intravenous immunoglobulin (0.5 g/kg/day for five days) was started, with no evidence of improvement after 48 h.
Follow-up MRI at six days showed progression in number and extension of hyperintense foci observed at the first examination, also compromising the bilateral sub-insular white matter and both internal capsules, with bilateral basement demyelinating MS characters.
Gd impregnation was no longer observed in this study.
The possibility of an EMAD was added intravenous boluses of methylprednisolone 500 mg daily for three doses, without clinical response.
Therefore, after one week of hospitalization, she received plasmapheresis for seven sessions, with progressive recovery of consciousness level and motor neurological deficit since the first session.
It was disconnected from IMV and a complete radiological regression was observed.
The patient was discharged and the three-year follow-up showed no clinical, imaging or recurrence sequelae.
