To the Editor: We read with interest the recently published article by Kamble and Rangaswamy [1]. The authors have reported a case of acute disseminated encephalomyelitis (ADEM) probably triggered by staphylococcal sepsis. We wish to add a few points.

Although methicillin-susceptible Staphylococcus aureus (MSSA) was isolated from the blood culture, the diagnosis of septic arthritis is still uncertain. The knee swelling and pain started four days before fever and synovial fluid examination findings are not available in this case. The isolation of MSSA in blood culture might be a contaminant, as staphylococcal group is the most common blood culture contaminant [2]. Knee joint arthritis might also be inflammatory arthritis, rather than septic arthritis. The plausible pathogenesis of staphylococcal superantigen triggering ADEM also seems improbable, as most of these children also have features of staphylococcal toxic shock syndrome and even diarrhea in a proportion of cases.

Similarly, diagnosis of ADEM is also uncertain, as the authors mentioned dramatic improvement immediately after the first dose of methyl prednisolone pulse, which is quite unusual with ADEM. The presence of fever at the onset of encephalopathy is also against the diagnosis of ADEM. The MRI images may also be seen in other clinical conditions in children with encephalopathy. Moreover, some virus like enterovirus, cytomegalovirus, Epstein-Barr virus, HIV and even scrub typhus sometimes cause encephalitis with white matter predominant signal changes [3]. In tropical regions, co-infection of multiple microorganisms is not uncommon. The etiological work-up performed in this case is incomplete to rule out all these causes. Authors have also not described cerebrospinal fluid (CSF) examination findings, CSF multiplex PCR results, other MRI sequences like Gadolinium enhanced sequences, DWI, ADC and FLAIR sequences.

Lastly, the authors have decided to administer methylprednisolone pulse despite evidence of active septicemia and bacteremia. Usually, high dose corticosteroids are deferred in patients with severe septicemia and septic arthritis, as this can suppress the natural immune response [4].