What are the general physical findings in Acute Disseminated Encephalomyelitis (ADEM)?

General Physical Findings in Acute Disseminated Encephalomyelitis (ADEM)

ADEM presents with encephalopathy (ranging from confusion to coma) as a required diagnostic feature, accompanied by multifocal neurologic deficits affecting the optic nerves, brain, brainstem, cerebellum, and spinal cord. 1, 2

Core Neurological Examination Findings

Mental Status and Behavioral Changes

• Encephalopathy is mandatory for diagnosis and manifests as confusion (76% of cases), disorientation (41%), behavioral changes, irritability, or altered consciousness ranging to coma 1, 2
• Speech disturbances occur in 59% of patients 1
• Fever is typically absent at the onset of neurological illness, despite often occurring 1-14 days after a preceding febrile infection or vaccination 3, 2

Focal Neurologic Deficits

• Focal neurological deficits are present in 36-78% of cases and reflect multifocal CNS involvement 1
• Motor deficits including weakness, paraplegia, or tetraplegia (often incomplete and painful) 1, 4
• Seizures occur in approximately one-third of patients 1

Cranial Nerve and Visual Findings

• Optic neuritis, frequently bilateral, with fundoscopic findings of papilledema during acute phase 3, 1, 2
• Ophthalmoplegia may be present in severe cases with brainstem involvement 5

Brainstem and Cerebellar Signs

• Brainstem encephalitis manifesting as cranial nerve palsies, dysarthria, dysphagia, or respiratory difficulties 1, 2
• Cerebellar ataxia with gait disturbance and coordination deficits 1, 2

Spinal Cord Findings

• Myelitis presenting with sensory level, sphincter disturbance (erectile and bladder dysfunction), and motor weakness 3, 1, 2
• Longitudinally extensive transverse myelitis is common 3, 2

Reflex Examination

• Pyramidal tract signs may be present with hyperreflexia and extensor plantar responses 5
• Unlike Guillain-Barré spectrum disorders, reflexes are typically preserved or increased rather than absent 5

Age-Specific Presentations

Pediatric Patients

• Non-specific symptoms including feeding difficulties and respiratory distress in young children 1
• Irritability and behavior changes may be the predominant early findings in up to 76% of pediatric cases 1

Important Clinical Caveats

• A normal Glasgow Coma Score does not exclude ADEM, as it may miss subtle behavioral changes that are diagnostically significant 1
• Subtle presentations with low-grade fever, speech disturbances, and behavioral changes can be mistaken for psychiatric illness 1
• Symptoms characteristically flare after tapering oral steroids, indicating steroid-dependence in some cases 3, 1
• The temporal relationship is critical: neurological symptoms typically develop 1-14 days post-vaccination or 1 week after rash appearance in exanthematous illness 3, 2

Systemic Examination Findings

• Fever is usually present during the prodromal infectious phase (up to 80% of cases) but absent when neurological symptoms begin 1, 2
• Rash or other signs of preceding viral infection (measles, mumps, rubella, varicella) may be evident 3, 2
• Respiratory or upper respiratory findings may suggest the precipitating infection 3