Treatment strategies for ADEM are largely derived from opinions of experienced clinicians, descriptive cohort studies, and/or reports from expert committees. Standard of care treatments in acute ADEM have not been proven by randomized, placebo-controlled trials.³ Since patients with ADEM usually present with fever, meningeal signs, acute encephalopathy, and evidence of inflammation in blood and CSF, it is important to first consider use of antibiotic and/or antiviral therapies (i.e., acyclovir) until an infectious cause is ruled out. High dose intravenous corticosteroids for 3-5 days is considered to be the first-line treatment for ADEM and can be used concurrently with antibiotics and acyclovir. Plasma Exchange (PLEX) should be considered in very aggressive forms of ADEM or if there is limited response to corticosteroids. Intravenous immunoglobulin (IVIG) can also be considered if PLEX is not available or there are contraindications to PLEX. The strength of evidence for the recommendation of corticosteroids and PLEX are graded as moderate. The strength of evidence for a recommendation of IVIG is poor. It should be noted that no studies have compared IVIG treatment with corticosteroids or plasma exchange, and there is debate over whether PLEX or IVIG should be used at the beginning, or only when corticosteroids fail to work.