Teaching neuroimages: call it as you see it: evolution of bilateral striatal necrosis.

After 2 days of fever, a 5-year-old boy had a partial seizure, then became encephalopathic and anarthric. MRI (figure) was consistent with bilateral striatal necrosis and Mycoplasma pneumonia immunoglobulin G and immunoglobulin M serology was positive. He was treated with plasma exchange and IV steroids with improvement in consciousness and speech. One month later he developed oromandibular, limb, and truncal dystonia. Clinical and radiologic improvement was observed after initiating rituximab. Aptly named, cases of bilateral striatal necrosis were described by Goutiéres and Aicardi1 in 1982. When attributable to an infectious or parainfectious etiology such as Mycoplasma, the prognosis is generally favorable.2