Acute disseminated encephalomyelitis (ADEM) is a demyelinating syndrome that typically presents with multifocal neurologic symptoms and encephalopathy. ADEM must be distinguished from certain childhood gliomas, which can have similar presentation like ADEM.

We discuss case with diagnosis of Glioma who were initially treated as ADEM based on clinical presentation and neuroimaging. 

A previously healthy 6 year old presented with diplopia, agitation and generalized tonic-clonic seizure in setting of febrile illness. Examination significant for left esotropia, bilateral papilledema. Rapid antigen testing was positive for Influenza B. LP was performed, analysis of CSF was normal and cultures were negative for viral, bacterial or fungal infections. Primary consideration based on initial MRI was encephalitis, which could be infectious, inflammatory, autoimmune or paraneoplastic in etiology, versus ADEM.

The diagnosis of acute hemorrhagic leukoencephalitis; an ADEM variant, was assumed and treatment of IVIG and steroids was started. IVIG for 5 days along with high dose steroids for 5 days followed by steroid taper for 3 weeks. Patient showed significant improvement in symptoms after IVIG and steroids. She was discharged from hospital on day 11 in stable condition. Within few days of steroid taper, patient was noted to have night time headaches and agitation. She was readmitted on 25 th day of discharge with Neurological examination significant for upgaze paralysis, and ataxia. Repeat MRI brain showed worsening imaging features. Due to worsening imaging changes; biopsy was performed. Histopathology reported as grade IV glioblastoma

Thus far, there have been few cases in literature with glioma which were initially treated as demyelinating disease. The above cases illustrate the significance of keeping diffuse glioma in the differential diagnosis of patients with ADEM type presentation. Whenever there is uncertainty based on clinical and radiologic features, biopsy should be thought about before making a decision.