Dengue virus is typically non-neurotropic recently more neurological complications are being reported. Neurological manifestations like encephalitis, myelitis, Guillain-Barré syndrome, hypokalemic paralysis and myositis are common. Acute disseminated encephalomyelitis (ADEM) in dengue is very rare and it may occur during the acute phase or post-infectious phase of dengue.

We report a rare case of a 55 years old woman, known hypertensive, who presented with left sided weakness, drowsiness, two-week history of low-grade relapsing fever and nonspecific headache. There was marked hypotonia and decreased power in the left upper and lower extremities. MRI showed diffuse white matter demyelination that was not contrast enhancing along with mass effect to the right side. CSF DR showed increased protein and decrease glucose levels. Upon not responding to antibiotics and steroids, MRI was repeated and there was increased demyelination with mass effect. Her dengue IgM came back positive. She was diagnosed to have ADEM secondary to dengue virus.   Since she was not responding to high dose steroids, plasmapheresis was advised but she left against medical advice.

Dengue is endemic in Pakistan and we see a surge of cases every year. Neurological involvement due to dengue is rare with non-response to steroids even rarer. Our case not only highlights a rare occurrence but also chalks out the management in a steroid non-responsive patient.