Neurophysiological Insights and Successful Aggressive Immunomodulation in Severe MOG-Associated Acute Disseminated Encephalomyelitis With Fulminant Bulbar Palsy: A Case Report

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) frequently presents as acute disseminated encephalomyelitis (ADEM) in pediatric and adolescent populations.While often steroidresponsive, severe cases with fulminant bulbar palsy and respiratory failure are rare and diagnostically challenging.We report a 15-year-old female patient who presented with acute quadriparesis, urinary retention, and rapidly progressive bulbar palsy requiring mechanical ventilation.Extensive laboratory evaluation, including cerebrospinal fluid (CSF) analysis and serum MOG-IgG testing using a live cell-based assay, was positive at a titer of 1:80, while cerebrospinal fluid oligoclonal bands were absent.Neurophysiological testing demonstrated absent F-wave responses in all tested nerves despite preserved distal motor and sensory conduction, indicating proximal motor pathway dysfunction.The patient was successfully managed with a stepwise escalation of immunomodulatory therapy -including pulse corticosteroids, therapeutic plasma exchange (PLEX), intravenous immunoglobulin (IVIG), and rituximab -ultimately leading to complete respiratory weaning and decannulation.This case underscores the diagnostic utility of early neurophysiological testing in predicting the severity of demyelination in MOG-ADEM.It highlights the efficacy of aggressive, sequential immunotherapy in achieving functional recovery in fulminant presentations.