We present an 18-year-old female with recent resolved upper respiratory infection who presented with fever, headache, and left hemiparesis, with rapid progression to quadriparesis, urinary retention, and encephalopathy. The hospital course involved autonomic dysfunction, prolonged intubation requiring tracheostomy and gastrostomy. Cerebrospinal fluid (CSF) showed pleocytosis, normal biochemical parameters with a positive MOG titer (1:40). Magnetic resonance imaging (MRI) showed extensive cervicothoracic T2 hyperintensity and brain multifocal T2 hyperintensities. Treatment included high dose steroids and Intravenous Immunoglobulin (IVIG) with recovery to baseline mentation and antigravity limb movements by discharge over two weeks. 

A 22-year-old male presented with progressive lower extremity paresthesia and weakness over six weeks. CSF demonstrated pleocytosis, normal glucose and elevated protein, oligoclonal bands and MOG antibody. MRI revealed multiple subcortical T2-hyperintense lesions and enhancing mid-cervical and lower thoracic lesions. Treatment with intravenous corticosteroids resulted in minor improvement with discharge on steroid taper and azathioprine. Patient’s disease progressed with a fluctuating course requiring two readmissions with bilateral upper extremity weakness, right optic neuritis, urinary sphincteric dysfunction with neuro-radiologic worsening. Treatment through multiple admissions included intravenous steroids, IVIG, plasmapheresis, Mycophenolate mofetil, and Rituximab with minimal improvement, symptom recurrence and progression of multifocal lesions. 

MOGAD has variable presentations like optic neuritis, transverse myelitis, or acute disseminated encephalomyelitis (ADEM), with or without encephalopathy. We present two rare cases of ADEM admitted within weeks of each other but distinct in severity and treatment responses, without any identifiable factors affecting clinical outcomes.