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NEUROIMAGE
Year : 2020  |  Volume : 68  |  Issue : 3  |  Page : 720-721

Giant Panda in ADEM


Department of Neurology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Web Publication6-Jul-2020

Correspondence Address:
Dr. Divya Nagabushana
Consultant Neurologist, Department of Neurology, People Tree Hospitals, Bengaluru - 560 022, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.289008

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How to cite this article:
Nagabushana D, Kumar S P, Nagaraj K. Giant Panda in ADEM. Neurol India 2020;68:720-1

How to cite this URL:
Nagabushana D, Kumar S P, Nagaraj K. Giant Panda in ADEM. Neurol India [serial online] 2020 [cited 2020 Aug 13];68:720-1. Available from: http://www.neurologyindia.com/text.asp?2020/68/3/720/289008




A 15-year-old girl presented with weakness and involuntary movements in the right upper limb and slurred speech for 1-month duration following a febrile illness. On examination, she had visual acuity of 6/9 and bilateral optic disc pallor. She had spastic dysarthria and mild spasticity of the right upper limb with intention tremor. Bilateral visual evoked potentials showed prolonged P 100 latencies. Cerebrospinal fluid (CSF) examination revealed four lymphocytes, 12 mg/dL of protein, and presence of oligoclonal bands. Magnetic resonance imaging (MRI) brain revealed T2W and FLAIR hyperintensities in bilateral deep periventricular, peritrigonal, subcortical white matter, internal capsule, and thalami. The brainstem was striking in appearance with “face of the giant panda” visualized on axial section of the midbrain [Figure 1]. Diagnosis of acute disseminated encephalomyelitis (ADEM) was made based on clinical presentation, abnormal visual evoked potential (VEP), CSF, and imaging findings. She was treated with intravenous steroids followed by oral course. She had complete resolution of symptoms after three months.
Figure 1: Axial T2-weighted MRI (a) “face of the giant panda” at the level of midbrain, (b) signal changes in left midbrain, (c) and axial FLAIR (d) MRI reveal hyperintense signal changes in the subcortical, periventricular white matter, thalami, and internal capsule

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The “face of the giant panda” was first described by Hitoshi et al. in Wilson's disease.[1] This appearance was attributed to high-signal intensity in the tegmentum and comparatively lower-signal intensity in the red nuclei, substantia nigra pars reticulate, and superior colliculi. In our patient, workup for Wilson's disease (24 h urinary copper level, serum copper, and ceruloplasmin) was negative. A literature review revealed that Leigh's disease, Japanese encephalitis, extra pontine myelinolysis, methyl alcohol poisoning, and hypoxic-ischemic encephalopathy are few of the other rare differential diagnoses for “face of the giant panda” on MRI.[2],[3] This case also exemplifies the variations in presentation of ADEM.[4]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hitoshi S, Iwata M, Yoshikawa K. Mid-brain pathology of Wilson's disease: MRI analysis of three cases. J Neurol Neurosurg Psychiatry 1991;54:624-6.  Back to cited text no. 1
    
2.
Sonam K, Bindu PS, Gayathri N, Khan NA, Govindaraju C, Arvinda HR, et al. The “double panda” sign in Leigh disease. J Child Neurol 2014;29:980-2.  Back to cited text no. 2
    
3.
Das SK, Ray K. Wilson's disease: An update. Nat Clin Pract Neurol 2006;2:482-93.  Back to cited text no. 3
    
4.
Kumar S, Alexander M, Gnanamuthu C. Heterogeneity in clinical presentation of acute disseminated encephalomyelitis (ADEM). Neurol India 2004;52:518-9.  Back to cited text no. 4
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