To describe a case of acute demyelinating encephalomyelitis (ADEM) in infancy following SARS-CoV-2 infection.

Neurological manifestations of COVID-19 in pediatric patients have been reported in the acute and post-infectious stages of the disease. ADEM typically presents in children following a viral illness at a mean age of 3-7 years. 60-90% of literature reported pediatric patients with ADEM have minimal to no neurologic deficits at long-term follow-up.

A 17-month-old developmentally typical girl presented to our northeast Florida children’s hospital with lethargy and inability to move bilateral upper extremities. Thirteen days before admission, she developed 5 days of fever and URI symptoms. On presentation, she was afebrile with notable irritability. The initial neurological exam was significant for left upper extremity rigidity, right upper extremity paresis, lower extremity hyperreflexia, truncal ataxia, and gait instability. Pertinent negatives include no cranial nerve findings or overt sensory deficits. During her hospital course, she became more somnolent for which she was transferred to the pediatric intensive care unit.

MRI brain with and without contrast revealed diffuse patchy T2 hyperintensities without evidence of contrast enhancement. MRI total spine with and without contrast was normal. SARS-CoV-2 nasal swab and antibody testing were positive. CSF analysis was unremarkable (WBC 5, RBC 1, glucose 58, protein 17, and oligoclonal bands 0). Respiratory viral panels, autoimmune encephalitis, and demyelinating disorders panel were negative. She was started on high dose steroids and IVIg with improvement in mental status with the ability to ambulate with minimal assistance. Following hospital discharge, she received inpatient rehab for 2 weeks.

Here, we report one of the first cases of post-COVID-19 ADEM in pediatric patients and the youngest to date. Early recognition of possible autoimmune and inflammatory complications of SARS-CoV-2, may lead to early aggressive immunomodulatory treatment and improved morbidity in these patients.