Sex: M
Vaccine: TDAP
Symptoms: CSF oligoclonal band absent, CSF protein increased, CSF red blood cell count positive, CSF white blood cell count increased, Central nervous system lesion
Clinical narrative: Acute disseminated encephalomyelitis (ADEM); myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD); migraine; retro-orbital headache / persistent headache; urinary retention; lymphocytic predominant pleocytosis; hemiparesis; Later impaired consciousness; Despite treatment with IV steroids, he deteriorated; venous sinus thrombosis; hemorrhage; visual disturbance; blurred vision in the left eye; vertigo; lower extremity weakness; difficulty with walking; urination; he also developed lower extremity paresthesia; altered mental status; language disturbance; vasogenic edema; neurocognitive deficits; inflammation; hemorrhagic leukoence phalomyelitis; This serious case was reported in a literature article and described the occurrence of acute disseminated encephalomyelitis in a 35-year-old male patient who received DTPa (Reduced antigen) (Tdap Vaccine) for prophylaxis.   Concurrent medical conditions included intubation.   On an unknown date, the patient received Tdap Vaccine. On an unknown date, 14 days after receiving Tdap Vaccine, the patient experienced acute disseminated encephalomyelitis (Verbatim: Acute disseminated encephalomyelitis (ADEM)) (serious criteria hospitalization, GSK medically significant, life threatening), myelin oligodendrocyte glycoprotein antibody-associated disease (Verbatim: myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD)) (serious criteria hospitalization, GSK medically significant and life threatening), migraine (Verbatim: migraine) (serious criteria hospitalization), headache (Verbatim: retro-orbital headache / persistent headache) (serious criteria hospitalization), urinary retention (Verbatim: urinary retention) (serious criteria hospitalization, GSK medically significant and clinically significant/intervention required), pleocytosis (Verbatim: lymphocytic predominant pleocytosis) (serious criteria hospitalization), hemiparesis (Verbatim: hemiparesis) (serious criteria hospitalization, GSK medically significant and clinically significant/intervention required), consciousness disturbed (Verbatim: Later impaired consciousness) (serious criteria hospitalization, GSK medically significant and clinically significant/intervention required), condition aggravated (Verbatim: Despite treatment with IV steroids, he deteriorated) (serious criteria hospitalization and clinically significant/intervention required), thrombosis of venous sinuses (Verbatim: venous sinus thrombosis) (serious criteria hospitalization and GSK medically significant), hemorrhage (Verbatim: hemorrhage) (serious criteria hospitalization), visual disturbance (Verbatim: visual disturbance) (serious criteria hospitalization), blurred vision (Verbatim: blurred vision in the left eye) (serious criteria hospitalization), vertigo (Verbatim: vertigo) (serious criteria hospitalization), lower extremities weakness of (Verbatim: lower extremity weakness) (serious criteria hospitalization), walking difficulty (Verbatim: difficulty with walking) (serious criteria hospitalization), urination difficulty (Verbatim: urination) (serious criteria hospitalization), paresthesia lower limb (Verbatim: he also developed lower extremity paresthesia) (serious criteria hospitalization), mental status changes (Verbatim: altered mental status) (serious criteria hospitalization and clinically significant/intervention required) and language disorder (Verbatim: language disturbance) (serious criteria hospitalization), vasogenic cerebral edema (Verbatim: vasogenic edema) (serious criteria hospitalization and GSK medically significant), neurocognitive deficit (Verbatim: neurocognitive deficits) (serious criteria hospitalization), inflammation (Verbatim: inflammation) (serious criteria hospitalization) and leukoencephalomyelitis (Verbatim: hemorrhagic leukoence phalomyelitis) (serious criteria hospitalization and GSK medically significant). The patient was treated with blood plasma (Plasma), tocilizumab, methylprednisolone and prednisone. The outcome of the acute disseminated encephalomyelitis, myelin oligodendrocyte glycoprotein antibody-associated disease, migraine, headache, urinary retention, pleocytosis, hemiparesis, consciousness disturbed, condition aggravated, thrombosis of venous sinuses, hemorrhage, visual disturbance, blurred vision, vertigo, lower extremities weakness of, walking difficulty, urination difficulty, paresthesia lower limb, mental status changes, language disorder, vasogenic cerebral edema, neurocognitive deficit, inflammation and leukoencephalomyelitis were resolving.   The reporter considered the acute disseminated encephalomyelitis, myelin oligodendrocyte glycoprotein antibody-associated disease, migraine, headache, urinary retention, pleocytosis, hemiparesis, consciousness disturbed, condition aggravated, thrombosis of venous sinuses, hemorrhage, visual disturbance, blurred vision, vertigo, lower extremities weakness of, walking difficulty, urination difficulty, paresthesia lower limb, mental status changes, language disorder, vasogenic cerebral edema, neurocognitive deficit, inflammation and leukoencephalomyelitis to be possibly related to Tdap Vaccine.     The company considered the acute disseminated encephalomyelitis, myelin oligodendrocyte glycoprotein antibody-associated disease, migraine, headache, urinary retention, pleocytosis, hemiparesis, consciousness disturbed, condition aggravated, thrombosis of venous sinuses, hemorrhage, visual disturbance, blurred vision, vertigo, lower extremities weakness of, walking difficulty, urination difficulty, paresthesia lower limb, mental status changes, language disorder, vasogenic cerebral edema, neurocognitive deficit, inflammation and leukoencephalomyelitis to be possibly related to Tdap Vaccine.   Additional Information: GSK Receipt Date: 22-Apr-2024 The author presented a case of a previously healthy 35-year-old man presented to an urgent care with 9 days of retro-orbital headache. Two weeks before symptom onset, he received tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination. He was diagnosed with migraine but returned to care 3 days later with persistent headache and new-onset urinary retention, visual disturbance (blurred vision in the left eye), and vertigo. MRI with contrast demonstrated an enhancing white matter T2/FLAIR hyperintense lesion in the anterior right lateral aspect of the pons with additional subcortical white matter lesions in the posterior right frontal lobe. There were anterior central T2 hyperintense lesions in the thoracic cord that enhanced with gadolinium. CSF analysis demonstrated a lymphocytic predominant pleocytosis (214 cells/µL) and elevated protein (61 mg/dL). There were no CSF-specific oligoclonal bands. He was treated with IV methylprednisolone (IVMP) 1,000 mg daily for 3 days and started intermittent bladder catheterization. Three days after IVMP, he returned to the emergency department with lower extremity weakness and difficulty with walking and urination. Despite additional IVMP followed by oral prednisone, his symptoms persisted, and he also developed lower extremity paresthesia. At an outpatient neurology appointment 10 days later, his examination was notable for hyperreflexia patellar stretch and extensor plantar responses. Blood was drawn for a comprehensive serologic evaluation, and he remained on prednisone 60 mg daily. Over the next few days, he developed worsened lower extremity weakness, altered mental status, and language disturbance. He was hospitalized because of alertness and required intubation. Brain MRI with contrast demonstrated new multifocal T2/FLAIR hyperintensities in the supratentorial white matter, corpus callosum, and basal ganglia with peripheral enhancement and extensive intralesional blood products. Hemorrhagic T2/ FLAIR hyperintensities of the bilateral thalami were noted with evidence of thrombosis of the bilateral internal cerebral veins, straight sinus, transverse sinus, and right sigmoid sinus. No lesions were noted on the spinal MRI at this time. CSF analysis showed RBC of 105 cells/µL, WBC of 87 cells/µL (85 percent polys), and 89 mg/dL protein.  He was transferred to a tertiary care center for further management. Serum MOG-IgG that had been drawn at his out-patient neurology appointment returned positive at a titer level of  1:1,000 by cell-based assay. CSF interleukin-6 (IL-6) level was elevated at 17,904.6 pg/mL (normal level less than or equal to 7.5 pg/mL.  Given his worsening despite IV steroid treatment, he underwent 5 sessions of plasma exchange (PLEX), and the cerebral venous sinus thrombosis (CVST), presumed secondary to inflammation from MOGAD, was treated with anticoagulation. He improved clinically, and this was attributed to PLEX treatment. Interval imaging showed decreased enhancement and a marked decrease in vasogenic edema surrounding numerous hemorrhagic lesions in the supratentorial brain. After his inpatient hospitalization, he was transferred to a rehabilitation hospital. Given the elevated CSF IL-6 level, he was started on the IL-6R antagonist tocilizumab 8 mg/kg every 4 weeks, which he has continued for more than one year. He completed a slow oral prednisone taper 10 months later. His serum MOG-IgG level remains positive at 1:1,000. Currently, he ambulates without assistance but struggles with neurocognitive deficits. He has not been able to return to work. In addition to the presentation of hemorrhagic leukoencephalomyelitis. The author also reported that It is possible that Tdap vaccination before the onset of neurologic symptoms contributed to this patient's development of ADEM and diagnosis of MOGAD.