Table 1.
Clinical Characteristics of 29 Patients with Central Nervous System Demyelination following SARS-CoV-2 Vaccination.
| No | Age (years) / Gender | Presenting Complaints | Total Duration of Illness | Type of Vaccine/ Dosing | Duration between the dose and first neurological symptom | Examination finding | Investigations | Treatment | Diagnosis |
|---|---|---|---|---|---|---|---|---|---|
| 1. | 29/F | Headache, Rt eye blurring of vision | 15 days | ChAdOx1 nCoV- 19 / 1st dose | 11 days | Rt: eye RAPD, VA – Rt: hand movement close to face; Lt - 6/6 | CSF: 0 cells, P:18 mg/dl, G: 61 mg/dl Serum and CSF OCB absent ANA, ANCA, RA factor, CRP -negative Serum MOG- positive VEP: Rt - absent waveform, Lt – normal MRI brain: T2 /FLAIR hyperintensity of long intraorbital segment of Rt optic nerve with contrast enhancement | Inj. MP 1 gm x 5 days 1 cycle of LVPP T. Prednisolone 40 mg OD followed by tapering doses | MOG-antibody –associated Rt Optic neuritis |
| 2. | 26/F | Bl calf pain, backache, Bl LL weakness & decreased sensation below D6 level | 11 days | BBV152 / 1st dose | 11 days | Quadriparesis with paradoxical breathing, Power- Bilateral upper limb between MRC grade 2–3, lower limb MRC grade 0, decreased sensation below D6, DTRs- 2+ in upper limb, absent in lower limb, plantars equivocal | CSF: 207 cells -polymorphic predominant, P: 95.8 mg/dl, G: 50 mg/dl, ANA profile- PCNA strongly positive; CRP – positive ANCA, RA factor -negative Serum NMO-MOG - negative SSEP- absent waveforms, MRI: Long segment T2/FLAIR hyperintensity from C2- L1 with post contrast enhancement, axial section showing H-shaped involvement | Inj. MP 1 gm x 5 days 5 cycles of LVPP T. Prednisolone 40 mg OD followed by tapering doses | Acute Transverse myelitis - LETM |
| 3. | 54/F | Progressive quadriparesis followed by altered sensorium | 1 month 12 days | ChAdOx1 nCoV- 19 / 1st dose | 14 days | Drowsy, not opening eyes, bl UL flexion posturing, quadriparesis with 2/5 power in UL and 0/5 power in LL. | CSF: 8 cells- lymphocytic predominant, P:77 mg/dl, G:98 mg/dl ANA, ANCA, CRP -negative Serum NMO-MOG- negative MRI brain: T2/FLAIR hyperintensities in the corpus callosum, bl periventricular and subcortical white matter, infratentorial region with patchy contrast enhancement | Inj. MP 1 gm x 5 days 5 cycles of LVPP Inj. Iv Ig 100 g T. Prednisolone 40 mg OD followed by tapering doses | ADEM |
| 4. | 44/M | Imbalance on walking, hiccups, vomiting, urinary retention, double vision | 12 days | ChAdOx1 nCoV- 19 / 1st dose | 7 days | Lt VA: 6/9, Rt – 6/6. spastic quadriparesis, bilateral cerebellar signs in UL | CSF: 130 cells- lymphocytic predominant, P: 38 mg/dl, G: 63 mg/dl, ANA, ANCA -negative Serum and CSF MOG- Strongly positive, MRI: T2 hyperintensities in the cervical and dorsal cord and conus | Inj. MP 1 gm x 5 days 5 cycles of LVPP T. Prednisolone 40 mg OD | MOG-antibody –associated – LETM |
| 5. | 50/F | Bl feet paraesthesias with LL weakness. | 3 weeks | ChAdOx1 nCoV- 19 / 1st dose | 28 days | Bl finger extensor weakness, Lt LL decreased distal vibration sense with spasticity in Bl LL | CSF: 2 cells - lymphocytic predominant, P:28 mg/dl, G:87 mg/dl ANA profile- PCNA weakly positive ANCA -negative, Serum NMO-MOG -negative, NCS –normal MRI Spine: focal cervical syrinx (C7-T1). demyelination across C6 | I/V MP-5 days T. Prednisolone 40 mg OD T. Amitriptyline 25 mg OD | Acute Transverse myelitis |
| 6. | 39/M | Rt eye pain followed by blurring of vision | 20 days | ChAdOx1 nCoV- 19 / 1st dose | 14 days | RT eye-RAPD, Rt VA: Finger counting at 2 m Visual field- right inferonasal quadrant involvement | ANA, ANCA, APLA -negative, Serum MOG- positive, VEP- bl prolonged (Right-132 ms, left-115 ms) MRI: T2 /FLAIR hyperintensity of long intraorbital segment of Rt optic nerve with contrast enhancement | Inj. MP 1 gm x 5 days T. Prednisolone 40 mg OD | MOG-antibody –associated Rt Optic neuritis |
| 7. | 54/M | Left eye blurring of vision | 3 weeks | ChAdOx1 nCoV- 19 / 1st dose | 14 days | VA: Bl 6/12, Lt eye RAPD present, Rt eye-normal pupillary reaction. | ANA profile anti Jo1 −1+ positive, ANCA,VDRL-negative, VEP: Rt- 127 ms, Lt-absent waveform Serum MOG –Strongly positive MRI brain and spine: T2/FLAIR hyperintensity in Rt pons | Inj. MP 1 gm x 5 days T. Prednisolone 40 mg OD | MOG associated optic neuritis |
| 8. | 34/M | Rt eye blurring of vision | 2 weeks | ChAdOx1 nCoV- 19 / 1st dose | 1 day | Rt eye- non reactive pupil, VA-perception of light present, Lt eye VA −6 /18 | CSF: 2 cells – lymphocyte, P: 26 mg/dl, G: 65 mg/dl ANA profile, ANCA,VDRL, RA factor, CRP-negative Serum and CSF NMO-MOG – negative VEP- absent waveform on Rt side MRI: Rt optic nerve tortuosity with prominent perioptic sheath and fat stranding | Inj. MP 1 gm x 5 days T. Prednisolone 40 mg OD | Rt eye optic neuritis |
| 9. | 35/F | Progressive paraparesis followed by altered sensorium | 8 days | ChAdOx1 nCoV- 19 / 1st dose | 9 days | Conscious, confused, VA: Bl 6/9, Bl LL paraparesis with power 1/5, DTRs- 3+ in upper limb, 2+ in lower limb, plantars- left extensor, right equivocal | CSF: 58 cells -lymphocytes P: 47.4 mg/dl, G: 106 mg/dl CRP- positive ANA profile, ANCA, VDRL, RA factor-negative Serum MOG-positive VEP, BERA, SSEP – normal MRI: T2/FLAIR hyperintensities in mid brain, pons, left MCP, bl posterior internal capsule, thalamus, bl centrum semiovale and LETM from cervical cord to conus | Inj. MP 1 gm x 5 days T. Prednisolone 40 mg OD | MOG-antibody –associated ADEM |
| 10. | 20/F | Double vision | 2 weeks | ChAdOx1 nCoV- 19 / 1st dose | 3 days | VA: Bl 6/6, Rt eye adduction restriction, Lt eye restriction in all gazes, fundus normal | CRP- Negative, ANA profile, ANCA -negative Serum NMO-MOG – negative MRI brain: Multiple discrete T2/FLAIR hyperintensities in pericallosal, callososeptal, periventricular, and fronto parietal regions | Inj. MP 1 gm x 5 days T. Prednisolone 40 mg OD | Brainstem syndrome |
| 11. | 31/M | Bladder disturbances followed by progressive numbness of whole body and LL weakness | 5 days | ChAdOx1 nCoV- 19 / 1st dose | 14 days | Lower limb spasticity, paraparesis with power 1/5, decreased sensations by 70% below L1, plantars extensor, UL DTRs-3+ and LL 2+ | CSF: 370 cells - polymorphic predominant, P: 174 mg/dl, G: 168 mg/dl ANA profile, ANCA,VDRL, RA factor, CRP-negative Serum and CSF NMO-MOG – negative VEP and BERA- normal, SSEP of Lt. LL prolonged (55.9 ms) MRI: long segment cervico-dorsal T2/FLAIR hyperintensity with subtle enhancement | Inj. MP 1 gm x 5 days T. Prednisolone 40 mg OD 7 cycles of LVPP Inj. Rituximab 1 gm (1st dose) | Acute Transverse myelitis - LETM |
| 12. | 20/F | Rt UL paraesthesias followed by paraparesis & altered sensorium | 2 days | BBV152 / 1st dose | 1 day | VA: Bl 6/6. LL proximal weakness (3/5), distal 4/5, DTRs- 3+, Rt LL −50% decreased sensation, Plantars Equivocal | CSF: 8 cells - lymphocytic predominant,P:24.9 mg/dl, G:61 mg/dl ANA profile, ANCA,VDRL, RA factor, CRP -negative Serum and CSF NMO-MOG negative, CSF OCB – Positive VEP, BERA, SSEP- normal MRI: few juxtacortical and short segment cervical T2/FLAIR hyperintensity at C5 level with subtle enhancement | Inj. MP 1 gm x 5 days T. Prednisolone 40 mg OD 5 cycles of LVPP | ADEM |
| 13. | 45/F | Bilateral (Rt followed by Lt) eye blurring of vision | 6 weeks | ChAdOx1 nCoV- 19 / 1st dose | 21 days | VA: Rt 6/12, Lt hand movement perception, Lt RAPD present, Rt eye-normal pupillary reaction, Lt upper limb spasticity and extensor plantar | CSF: 2 cells - lymphocytic predominant, P: 52.3 mg/dl, G: 95 mg/dl CSF OCB- positive ANA profile, ANCA, RA factor, CRP-negative Serum MOG panel- strongly positive VEP: Bl waveform absent, BERA AND SSEP-Normal MRI brain and spine-T2/FLAIR short segment hyperintensity with enhancement of bilateral optic nerves, Rt optic nerve tortuous | Inj. MP 1 gm x 5 days T. Prednisolone 40 mg OD 3 cycles of LVPP | MOG associated optic neuritis |
| 14. | 33/F | Fever, vomiting followed by altered sensorium and persistent paraesthesias below mid thoracic level | 4 weeks | ChAdOx1 nCoV- 19 / 1st dose | 14 days | VA: Rt 6/12, Lt 6/9, Bl normal pupillary reaction, no other focal deficits | CSF: 105 cells - lymphocytic predominant, P: 28.12 mg/dl, G: 70.4 mg/dl Serum MOG –Strongly positive MRI brain: T2/FLAIR hyperintensity in Bl fronto parietal region, no enhancement | Inj. MP 1 gm x 5 days T. Prednisolone 40 mg OD Inj. Acyclovir 500 mg TID (treated outside) | MOG- associated ADEM |
| 15. | 53/F | Bl LL numbness, tingling paraesthesias & urinary disturbances | 12 days | ChAdOx1 nCoV- 19 / 2nd dose | 1 day | Tone and Power normal, Touch and pain sensation reduced by 75% below T4, Vibration sense reduced upto T4, plantars Bl equivocal, DTRs-UL 2+ and LL 3+ | CSF: 6 cells - lymphocytic predominant, P: 54.2 mg/dl, G: 77 mg/dl ANA, ANCA,VDRL, RA factor, CRP-negative ACE- 31.4 U/L Paraneoplastic panel:Anti – recoverin 2+ VEP-prolonged bl 123 ms, BERA, SSEP -normal Serum NMO MOG –negative MRI brain and spine: T2/FLAIR hyperintensity at Bl subcortical, periventricular deep white matter, insula, cerebellar hemispheres, brainstem, short segment expansile T2 hyperintensities are noted at C5,6,7 & D6–7 levels | Inj. MP 1 gm x 5 days T. Prednisolone 40 mg OD | Acute Transverse myelitis – LETM |
| 16. | 38/M | Giddiness, double vision, imbalance while walking, right eye blurring of vision followed by headache | 20 days | ChAdOx1 nCoV- 19 / 2nd dose | 6 days | VA:Rt 6/9, Lt 6/6, Bl normal pupillary reaction, Bl gaze evoked horizontal and torsional nystagmus, DTRs: 3+, plantars Bl extensor. | CSF: 6 CELLS; P: 67.8 mg/dl, G: 81 mg/dl ANA, ANCA,VDRL, RA factor, CRP-negative ACE- 20.7 U/L VEP-prolonged, BERA, SSEP -normal Serum NMO MOG –negative MRI brain and spine: T2/FLAIR hyperintensity in left MCP, right corona radiate with no contrast enhancement | Inj. MP 1 gm x 5 days T. Prednisolone 40 mg OD | CNS demyelination |
| 17 | 30/M | Sequential blurring of vison in both eyes | 11 days | ChAdOx1 nCoV- 19 / 1st dose | 14 days | VA: Rt eye-absent perception of light, Lt eye-2/60 Fundi: Bl Disc oedema | CSF: 4 cells – 50% lymphocytes, P:26.8 mg/dl, G:108 mg/dl, OCBs-positive ANA profile and ANCA -negative, Serum NMO-MOG -negative, VEP-Bl not recordable, BERA and SSEP-Normal MRI brain: subcortical hyperintense foci in Bl cerebral hemispheres MRI Optic nerves:Right>left intraneural hyperintensities in intraorbital segments | Inj MP 1 gm x 5 days 5 cycles of LVPP Inj Rituximab | Bilateral optic neuritis |
| 18 | 30/F | Paraesthesias over both palms followed by development of girdle like sensation over waist and electric shock like sensation on flexion of neck | 90 days | ChAdOx1 nCoV- 19 / 1st dose | 15 days | VA-6/6 Bl, Cranial nerves and motor examination-normal Sensory examination-40% decreased sensation to touch over both palms, Romberg's-negative | CSF: 4 cells,P-36 mg/dl, G: 60 mg/dl, OCB positive CRP-positive,ESR-68 mm/hr ANA, ANCA,VDRL, RA factor-negative, Vitamin B12, homocysteine-normal, ACE- 24.2 U/L Evoked potentials -normal Serum NMO MOG –negative MRI brain and spine: single focus of T2/flair hyperintensity in selenium of corpus callosum, short segment hyperintensity in cervical cord along C3. | Inj MP 1 gm x 5 days 3 cycles of LVPP T. MMF (1.5 gm/day) | ATM - Cervical cord demyelination |
| 19 | 36/M | Bl LL tingling and paraesthesias followed by development of motor weakness and urinary disturbances | 20 days | ChAdOx1 nCoV- 19/2nd dose | 32 days | VA: Rt (aphakia): PL present, left: 6/9. Cranial nerves-normal Upper limbs: motor and sensory examination-normal Lower limbs: hypotonia, power: hip joint: Bl 1/5, Knee joint: Bl 0/5, Ankle joint: Bl 1/5, DTRs;absent in lower limbs. Sensory level at D4 | CSF: 720 cells – 80% lymphocytes P: 144.4 mg/dl, G: 50 mg/dl ANA, ANCA,VDRL, RA factor, CRP-negative, ACE- 60.9 U/L Serum NMO-negative Serum MOG-Strongly positive MRI brain: hyperintensities along bilateral trigeminal nerves in pons MRI spine: long segment spinal cord involvement from obex till conus | Inj MP 1 gm x 7 days 5 cycles of LVPP | MOG associated LETM |
| 20 | 27/F | Ill-defined pain followed by weakness in left upper and lower limb, followed by right lower limb involvement, requiring a person support to walk | 26 days | ChAdOx1 nCoV- 19 / 1st dose | 8 days | VA-6/6 Bl, Cranial nerves -normal Motor examination- grade I spasticity in left upper limb, mild pronator drift, DTRs brisk. Sensory examination-normal | CSF: clear, P: 27.7 mg/dl, G: 62 mg/dl ANA, ANCA,VDRL, RA factor, CRP-negative, ACE-normal EPs- Normal Serum NMO and MOG-negative MRI brain: multifocal discrete hyperintense T2/flair lesions in Bl periventricular white matter with few lesions showing peripheral diffusion restriction and contrast enhancement. MRI spine-normal | Inj MP 1 gm x 5 days T. Prednisolone 40 mg OD | CNS demyelination |
| 21 | 60/M | Acute onset tingling paraesthesias and motor weakness in left upper and lower limb, followed by behavioural and memory disturbances | 34 days | ChAdOx1 nCoV- 19 / 2nd dose | 14 days | MMSE-27/30 Cranial nerves-VA:R-6/6, l- 6/9, nystagmus present Motor system-Power: normal,DTRs-brisk | CSF: 9 cells – 90% lymphocytes, P:68.3 mg/dl, G:132 mg/dl, OCBs-negative ANA,ANCA,B12,Homocysteine,VDRL-negative,ACE-normal Serum NMO and MOG -negative, VEP-normal MRI brain: multiple focal lesions in right pons, midbrain, medial temporal lobes, splenium of corpus callosum, high parietal lobe with tumefaction and peripheral enhancement | Inj MP 1 gm x 5 days T. Prednisolone 40 mg OD T. MMF(1 gm) | ADEM |
| 22 | 23/F | Burning paraesthesias in right palm associated with numbness and motor weakness followed by burning sensation in right foot over next 7 days | 41 days | ChAdOx1 nCoV- 19 / 2nd dose | 7 days | VA-6/6 Bl Cranial nerves-normal Motor system-normal Sensory system-decreased vibration along distal right upper and lower limb joints | CRP- 23 mg/dl ANA-negative Serum NMO and MOG-negative CSF-OCB negative MRI brain-T2/flair hyperintensities adjacent to right frontal horn, ependymal margins of bilateral lateral ventricles MRI spine-short segment hyperintensities at C2-C3,C5,D4 | Inj MP 1 gm x 5 days T. Prednisolone 40 mg OD | Cervical cord myelopathy |
| 23 | 40/M | Blurring of vision from left eye followed by acute urinary retention and right eye vision loss | 77 days | ChAdOx1 nCoV- 19 / 1st dose | 10 days | VA- 6/18 Bl Cranial, motor and sensory examination-normal | CSF: 8 cells – 100% lymphocytes, P:32 mg/dl, G:68 mg/dl,OCB-positive ANA,ANCA,VDRL -negative, Serum MOG -positive MRI brain: T2 Hyperintensities in pons, bilateral thalami, right frontal cortex MRI spine-longitudinally extensive myelitis from C4-D3 | Inj MP 1 gm x 5 days T. Prednisolone 60 mg OD T. MMF (2 gm) | MOG associated Opticomyelopathy |
| 24 | 45/M | H/o fever accompanied by urinary retention and difficulty in walking progressing to altered sensorium | 5 days | ChAdOx1 nCoV- 19 / 1st dose | 10 days | VA-6/6 BL Cranial nerves-normal Motor system-Tone and power normal in upper limbs LL-hypotonia, grade-0 power with hyporeflexia, plantars mute | CSF: 44 cells – 44% lymphocytes, P:90.9 mg/dl, G:68 mg/dl, rabies CSF PCR-Negative VEP-l-141,R-129,BERA-normal, N20-normal, P37–40(mildly prolonged), ANA-U1RNP-1+,C-ANCA-, Serum MOG – strongly positive S.NMO—Negative MRI of brain and spine-hyperintensities in brainstem, cervicodorsal cord and supratentorial regions with central cord swelling | INJ MP-5 days, LVPP 3 CYCLES TAB WYSOLONE 40 MG TAB MMF 1.5 GM | MOG-ADEM |
| 25 | 34/F | H/o recurrent vomiting and hiccups progressing to imbalance while walking | 60 days | ChAdOx1 nCoV- 19 / 2nd dose | 36 days | Cranial nerves: Right gaze evoked nystagmus, rest normal Motor examination::Tone and power normal, DTRs brisk BL Sensory examination: pseudoathetosis Left>Right,, Romberg's positive, Tandem gait impaired | CSF-1 cell,P-15,3 mg/dl,−63 mg/dl,OCB Negative ESR-46 mm/hr Serum NMO-weakly positive Serum MOG-negative ANA:Ro-52 1+,ANCA-negative MRI brain:T2 hyperintensity in dorsal aspect of medulla | I/V MP-5 days LVPP-3 cycles Tab Wysolone 40 mg Inj Rituximab | Area postrema syndrome - Aquaporin 4 positive NMO |
| 26 | 31/M | H/o progressive upper and lower limb tingling f/b difficulty in walking, urinary urgency, and constipation | 17 days | ChAdOx1 nCoV- 19 / 1st dose | 42 days | Cranial nerves-normal UL motor examination-normal, LL power-4/5,brisk DTRs, extensor plantars Sensory level at T4 | CSF: 32 cells – 100% lymphocytes, P:49.2 mg/dl, G:74 mg/dl ANA,ANCA,VDRL -negative, Serum NMO and MOG -negative MRI brain: T2 Hyperintensities in cervicomedullary junction, right frontal subcortical region MRI spine-cervical cord HI C2-C5,also in dorsal cord | I/V MP-5 days LVPP-4 cycles Tab Wysolone 40 mg Tab MMF 1.5 gm | ATM – acute transverse myelitis |
| 27 | 52/F | H/o progressive slurring of speech with right upper limb and lower limb weakness, followed by appearance of swallowing difficulty | 51 days | ChAdOx1 nCoV- 19 / 1st dose | 35 days | Spastic anarthria+ Gaze restricted left>right Right facial weakness Motor examination-hypotonic right upper and lower limb with 0/5 power, left sided power-5/5,BL DTRs brisk and plantars extensor | CSF-2 CELLS,P-40.5 mg/dl,G-56 mg/dl ESR-18,CRP-POSITIVE ANA,ANCA-Negative, VDRL-Negative S.NMO and MOG-Negative MRI brain:tumefactive demyelination in left frontal hemisphere with insular involvement along with left more than right midbrain involvement | I/V MP-5 days LVPP-4 cycles Tab Wysolone 40 mg Inj Rituximab | ADEM - Tumefactive demyelination |
| 28 | 65/F | H/o urinary retention followed by numbness and weakness of both hands and blurring of vision of right eye | 30 days | ChAdOx1 nCoV- 19 / 1st dose | 42 days | V/A-R- hand movements close to face,L-6/18 UL: motor examination normal LL: Power-0/5 DTRs absent in LL Sensory level:T6 | CSF-17 CELLS,P-49 mg/dl,G-59 mg/dl ESR-97 ANA,ANCA-Negative, VDRL-Negative S.NMO-Strongly positive S.MOG-Negative VEP-R-Not recordable, l-Normal SSEP-LL absent MRI brain: few hyperintensities in frontal subcortical white matter MRI Spine: D2-D11 hyperintensity with patchy contrast enhancement and bright spotty areas | LVPP – 3 cycles I/V MP-5 days Tab Wysolone 40 mg Tab MMF 1.5 gm | LETM - Aquaporin 4 positive NMO |
| 29 | 20/F | H/o tingling in tips of right hand followed by progressive imbalance while walking | 24 days | ChAdOx1 nCoV- 19 / 2nd dose | 39 days | V/A-6/6 BL Motor examination: Tone increased in right upper limb and lower limb Power - 5/5 in all 4 limbs DTRs: normal Plantar right extensor and left flexor Sensory system- Pain and touch decreased by 10 percent in right upper and lower limb JPS normal Vibration normal Romberg positive Gait ataxic | CSF- 4 CELLS,P-23 mg/dl,G-111 mg/dl,CSF- OCB+ ANA-,ANCA-,CRP-13 mg/dl,,EBV-IGG+ S.NMO and MOG-Negative MRI brain: hyperintensities in BL juxtacortical, subcortical, periventricular white matter, anterior temporal lobes as well as infratentorial regions including pons, MCP and medulla MRI Spine: short segment lesions in cervical and dorsal spine | I/V MP-5 days Tab Wysolone 40 mg Inj Rituximab | Cervical myelopathy - MS |
Abbreviations: No: number; F: female; Rt: right; RAPD: Relative afferent pupillary defect; VA: visual acuity; Lt: left; CSF: cerebrospinal fluid; P: protein; mg/dl= milligrams per decilitres; G: glucose; ANA: antinuclear antibodies; ANCA: antineutrophil cytoplasmic antibodies; RA: rheumatoid factor; CRP: C -reactive protein; MOG: myelin oligodendrocyte glycoprotein; OCB: oligoclonal band; VEP: visual evoked potential; MRI: magnetic resonance imaging; T2/ FLAIR: T2 weighted/ Fluid- attenuated inversion recovery; Inj.: Injection; MP: Methylprednisolone; LVPP: large volume plasmapheresis; T: tablet; OD: omne in die; once daily; Bl: bilateral; LL: lower limbs; D: Dorsal cord level; MRC: Medical research council; DTRs: deep tendon reflexes; PCNA: proliferating cell nuclear antigen; NMO: Neuromyelitis optica; SSEP: somatosensory evoked potential; C: cervical cord level; L: lumbar cord level; LETM: longitudinally extensive transverse myelitis; UL: upper limbs; Iv Ig: Intravenous immunoglobulin; ADEM: Acute disseminated encephalomyelitis; M: male; NCS: nerve conduction studies; APLA: Antiphospholipid antibodies; ms: milliseconds; VDRL: venereal disease research laboratory test; BERA: Brain Evoked Response Auditory; MCP: middle cerebellar peduncles: TID: ter in die; thrice daily; ACE: angiotensin-converting enzyme; BD: bis in die twice daily; MS: Multiple Sclerosis.