Silent triggers and symmetric peduncles - a rare presentation of adult-onset acute disseminated encephalomyelitis: A case report

Table 1 Chronological timeline of clinical course and management

Day of illness	Event
0	Onset of high-grade fever and severe headache
2	Acute left facial paralysis
4	Progressive left hemiparesis (unable to walk/self-feed)
7	Focal seizure (right leg); hospital admission
8	Brain MRI + lumbar puncture performed
8-14	Persistent encephalopathy; fever resolution by Day 14
21	Spontaneous neurological improvement noted (strength/alertness)
22	High-dose IV methylprednisolone initiated (1 g/day)
22-26	IV methylprednisolone continued (5-day course)
27	Transition to oral prednisone taper (60 mg/day starting dose)
28	Transferred to rehabilitation ward; physiotherapy started
42	Motor strength 4/5; independent ambulation; discharged

MRI: Magnetic resonance imaging.

Table 2 Summary of clinical presentation, investigations, and treatment

Presenting symptoms	High-grade fever, severe headache, left facial paralysis, hemiparesis, reduced level of consciousness, photophobia, phonophobia, nausea, vomiting, focal seizure (right leg)
Neurological exam	Left LMN facial palsy, left hemiparesis (UL 3/5, LL 2/5), encephalopathy, mild ptosis
CSF analysis	Clear; elevated protein (76 mg/dL); lymphocytic pleocytosis; normal glucose; negative Gram stain, culture, and viral PCR (HSV, VZV, Japanese encephalitis virus)
MRI brain	Bilateral, symmetric T2/FLAIR hyperintensities in middle cerebellar peduncles; subtle changes in pons and periventricular white matter; no diffusion restriction, no enhancement
Other workup	EEG: Diffuse slowing (encephalopathy); Normal renal/Liver function; relative lymphopenia; mild transaminitis
Negative serology	ANA, aquaporin-4, MOG-Ab, HIV, syphilis, TB (ADA)
Treatment & outcome	Delayed IV methylprednisolone (5-day course) followed by oral taper; spontaneous improvement before treatment; complete motor recovery

LMN: Lower motor neuron; UL: Upper limb; LL: Lower limb; PCR: Polymerase chain reaction; HSV: Herpes simplex virus; VZV: Varicella zoster virus; MRI: Magnetic resonance imaging; FLAIR: Fluid-attenuated inversion recovery; EEG: Electroencephalogram; ANA: Antinuclear antibody; MOG-Ab: Myelin oligodendrocyte glycoprotein antibody; HIV: Human immunodeficiency virus; TB: Tuberculosis; ADA: Adenosine deaminase.