Abstract

1. Cognitive and Functional Improvement in a Pediatric Patient with Acute Disseminated Encephalomyelitis Following Methylphenidate Treatment: A Case Report Jessica L. Colyer, MD and Chad A. Walters, DO University of Kentucky Department of Physical Medicine and Rehabilitation, Lexington, KY Discussion Acute disseminated encephalomyelitis (ADEM) is an immune-mediated CNS demyelinating disease that usually follows a benign infection in healthy young people and often presents as an acute encephalopathy with multifocal neurologic signs and deficits Most patients are treated via supportive measures and often with IV methylprednisolone for 3-5 days and/or administration of IVIg—sequelae vary, but most patients eventually recover from this disease process. Much study has been performed on neurostimulant use in the TBI population regarding general cognitive function, attention, processing time and executive functioning; however, study of the use of neurostimulants following infection and auto-immune disorders has been very limited. Methylphenidate was used successfully as a neurostimulant in this pediatric patient with ADEM. Methylphenidate aided in improving arousal and attention in this patient, which contributed to the efficacy of her therapy sessions. Further investigation and controlled studies would be warranted in the future References Young NP, Weinshenker BG, and Lucchinetti CF. Acute disseminated encephalomyelitis: current understanding and controversies. Semin Neurol 2008; 28:84-94. Leake JA, Albani S, Kao AS, et al. Acute disseminated encephalomyelitis in childhood: epidemiologic, clinical and laboratory features. Pediatr Infect Dis J 2004; 23(8):756-764 Weber P, Lütschg J. Methylphenidate treatment. Pediatr Neurol 2002 Apr;26(4):261-6 Hornyak JE, Nelson VS, and Hervitz EA. The use of methylphenidate in paediatric traumatic brain injury. Pediatr Rehabil 1997 Jan-Mar;1(1):15-7 Warden DL, Gordon B, McAllister TW, et al. Guidelines for the Pharmacologic Treatment of Neurobehavioral Sequelae of Traumatic Brain Injury. J Neurotrauma 2006; 23(10): 1468-1501 Abstract Setting: Acute rehabilitation hospital. Patient: A 4-year-old girl with acute disseminated encephalomyelitis (ADEM). Case Description: The patient was admitted to the brain injury unit of an acute rehabilitation hospital 10 days after diagnosis and treatment at a pediatric hospital. Residual effects from the disease process in this patient included flaccid limbs and generalized weakness with total dependence required for many activities of daily living (ADLs), cognitive slowing with decreased verbalization and play, and lethargy. After 1 week of inpatient rehabilitation, patient made no functional or cognitive gains. Plans were made to start patient on a neurostimulant. Patient was on daily dosing of amantadine for 1 day; however, this was not tolerated secondary to severe nausea and vomiting. Daily dosing of 2.5 mg oral methylphenidate (MPH) was initiated on rehab day 10. This dosage was titrated to 2.5 mg twice daily dosing (administered at 7 AM and noon) on rehab day 14. Assessment/Results: Prior to the administration of MPH, the patient remained lethargic and made poor functional gains during her acute inpatient rehabilitation stay. Within 24 hours of the initiation of MPH, the patient’s condition markedly improved, including increased alertness and ability to communicate, increased age-appropriate play, and improved performance of ADLs. Discussion: MPH is a mild central nervous system stimulant that is indicated by the FDA for use in the treatment of attention deficit disorder and narcolepsy. MPH has also been used off label for decades for the treatment of cognitive dysfunction in traumatic brain injury in both the adult and pediatric population. MPH aided in improving arousal and attention in this patient, which contributed to the efficacy of her therapy sessions. Conclusion: MPH was used successfully as a neurostimulant in this pediatric patient with ADEM. Further investigation and controlled studies would be warranted in the future. Key Words: Acute disseminated encephalomyelitis; Methylphenidate; Pediatrics; Rehabilitation Figure 1: Timeline of patient’s course Figure 2: Representative MRI images of patient’s brain (FLAIR and T2 weighed) There are ill-defined areas of high signal seen in bilateral basal ganglia without evidence of contrast enhancement. These areas of abnormality include bilateral putamen, caudate nucleus, lentiform nucleus and also additionally the subcortical white matter in the frontal region and the frontal lobe appears involved.