Consensus definitions proposed for pediatric multiple sclerosis and related disorders

Characteristics of pediatric multiple sclerosis: A tertiary referral center study

Objective

The present study represents one of the largest series of pediatric multiple sclerosis (PedMS) in Western Balkan region. This is the first study aimed to evaluate the characteristics of PedMS in the Serbian population.

Methods

This retrospective study on 54 PedMS, aged 7–17 years, was performed at the Clinic of Neurology and Psychiatry for Children and Youth in Belgrade, Serbia, a tertiary center for the diagnosis and treatment of children with neurological and psychiatric diseases.

Results

Female to male ratio was 37 (68.5%): 17 (31.5%). Family history of MS was noted in 9.3% and autoimmune diseases in 24.1% patients. Co-occurring migraine was in 7,4%. Monofocal onset of disease was present in 77.8% patients. The most common initial symptoms were optic neuritis (37%), sensory disturbances (31.5%), motor deficit (24.1%), cerebellar (18.5%) and brainstem lesions (16.7%), pain (9.3%), acute disseminated encephalomyelitis like symptoms (1.9%), and hearing loss (3.7%). Visual evoked potentials were pathological in 75.9% of patients. Oligoclonal bands were positive in 68.5% of patients. Magnetic resonance imaging showed periventricular (94.4%), infratentorial (77.8%), juxtacortical and cortical changes (55.6%) and changes in the cervical spinal cord (33.3%). The median EDSS score was 2.0.

Conclusion

Our cohort significantly differs from the literature data regarding more frequent occurrence of optic neuritis, hearing loss as a first symptom, the relapsing-remitting course of the disease, higher proportion of early onset of disease, presence of co-occurring migraine and the frequent occurrence of epilepsy and other autoimmune diseases in the family.

Silent New Brain MRI Lesions in Children with MOG-Antibody Associated Disease

Anti-myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG) antibodies are associated clinically with either a monophasic or relapsing disease course. We investigated the frequency and clinical importance of acquired asymptomatic brain magnetic resonance imaging (MRI) lesions in a prospective incident cohort of 74 MOG-IgG positive children with serial MRI scans over a median of 5 years from presentation. Silent new lesions were detected in 14% of MOG-IgG positive participants, most commonly within the first months post-onset, with a positive predictive value for clinically relapsing disease of only 20%. Detection of asymptomatic lesions alone need not prompt initiation of chronic immunotherapy. ANN NEUROL 2021;89:408-413.

Serial Anti-Myelin Oligodendrocyte Glycoprotein Antibody Analyses and Outcomes in Children With Demyelinating Syndromes

Question

Are antibodies to myelin oligodendrocyte glycoprotein (MOG) associated with relapses in children with acquired demyelination?

Findings

In this cohort study including 274 children with acquired demyelinating syndrome, anti-MOG antibodies were found in approximately 30% of children at presentation; they were more frequent in children with acute disseminated encephalomyelitis or younger than 11 years and were rarely present in children meeting multiple sclerosis diagnostic criteria. Neither presence of anti-MOG antibodies at onset nor their subsequent persistence were strongly associated with relapsing disease.

Meaning

While common in children with demyelination, anti-MOG antibodies should not be used to adjudicate long-term immunomodulatory therapy in the absence of clinical relapsing disease.

Importance

Identifying the course of demyelinating disease associated with myelin oligodendrocyte glycoprotein (MOG) autoantibodies is critical to guide appropriate treatment choices.

Objective

To characterize serial anti-MOG antibody serologies and clinical and imaging features at presentation and during follow-up in an inception cohort of prospectively monitored children with acquired demyelination.

Design, Setting, and Participants

In this prospective cohort study, study participants were recruited from July 2004 to February 2017 through the multicenter Canadian Pediatric Demyelinating Disease Study. Inclusion criteria included (1) incident central nervous system demyelination, (2) at least 1 serum sample obtained within 45 days from onset, and (3) complete clinical information. Of 430 participants with acquired demyelinating syndrome recruited, 274 were included in analyses. Of 156 excluded participants, 154 were excluded owing to missing baseline samples and 2 owing to incomplete clinical information. Data were analyzed from May to October 2018.

Main Outcomes and Measures

Presence of anti-MOG antibodies was blindly assessed in serial samples collected over a median of 4 years. Clinical, magnetic resonance imaging, and cerebrospinal fluid features were characterized at presentation, and subsequent disease course was assessed by development of new brain magnetic resonance imaging lesions, total lesion volume at last evaluation, annualized relapse rates, Expanded Disability Status Scale score and visual functional score at 4 years, and any disease-modifying treatment exposure.

Results

Of the 274 included participants, 140 (51.1%) were female, and the median (interquartile range) age of all participants was 10.8 (6.2-13.9) years. One-third of children were positive for anti-MOG antibodies at the time of incident demyelination. Clinical presentations included a combination of optic neuritis, transverse myelitis, and acute disseminated encephalomyelitis for 81 of 84 anti-MOG antibody–positive children (96%). Brain lesions were present in 51 of 76 anti-MOG antibody–positive participants (67%), but magnetic resonance imaging characteristics differed with age at presentation. Complete resolution of baseline lesions was observed in 26 of 49 anti-MOG antibody–positive participants (53%). On serial serum analysis, 38 of 67 participants (57%) who were seropositive at onset became seronegative (median time to conversion, 1 year). Among all participants who were positive for anti-MOG antibodies at presentation, clinical relapses occurred in 9 of 24 children (38%) who remained persistently seropositive and in 5 of 38 children (13%) who converted to seronegative status.

Conclusions and Relevance

Myelin oligodendrocyte glycoprotein antibodies are common in children with acquired demyelinating syndrome and are transient in approximatively half of cases. Even when persistently positive, most anti-MOG antibody–positive children experience a monophasic disease. The presence of anti-MOG antibodies at the time of incident demyelination should not immediately prompt the initiation of long-term immunomodulatory therapy.

Progress in the Management of Paediatric-Onset Multiple Sclerosis

Considerable progress has been made in the understanding and treatment of paediatric-onset multiple sclerosis (POMS); how this has translated into more effective care is less well understood. Here, we evaluate how recent advances have affected patient management and outcomes with a retrospective review of POMS patients managed at two paediatric neuroimmunology centres. Two cohorts, seen within a decade, were compared to investigate associations between management approaches and outcomes. Demographic, clinical and neurocognitive data were extracted from case notes and analysed. Of 51 patients, 24 were seen during the period 2007-2010 and 27 during the period 2015-2016. Median age at onset was 13.7 years; time from symptom onset to diagnosis was 9 months. Disease-modifying therapies were commenced in 19 earlier-cohort and 24 later-cohort patients. Median time from diagnosis to treatment was 9 months for earlier vs. 3.5 months in later patients (p = 0.013). A wider variety of treatments were used in the later cohort (four medications earlier vs. seven in the later and two clinical trials), with increased quality of life and neurocognitive monitoring (8% vs. 48% completed PedsQL quality of life inventory; 58% vs. 89% completed neurocognitive assessment). In both cohorts, patients were responsive to disease-modifying therapy (mean annualised relapse rate pre-treatment 2.7 vs. 1.7, mean post-treatment 0.74 vs. 0.37 in earlier vs. later cohorts). In conclusion, over the years, POMS patients were treated sooner with a wider variety of medications and monitored more comprehensively. However, this hugely uncontrolled cohort did not allow us to identify key determinants for the improvements observed.

Acute Disseminated Encephalomyelitis: Current Perspectives

Acute disseminated encephalomyelitis (ADEM) is an immune-mediated central nervous system (CNS) disorder, characterized by polyfocal symptoms, encephalopathy and typical magnetic resonance imaging (MRI) findings, that especially affects young children. Advances in understanding CNS neuroimmune disorders as well as the association of myelin oligodendrocyte glycoprotein antibody (MOG-Ab) with both monophasic and recurrent forms of ADEM have led to new insights into its definition, management and outcome. In this review, we aim to provide an update based on current epidemiologic, clinical, radiological and immunopathological aspects and clinical outcome of ADEM.

Frequency and etiology of acute transverse myelitis in Southern Finland

OBJECTIVE

Acute transverse myelitis is a relatively rare, frequently debilitating but potentially treatable emergency. The objective of this study was to evaluate the incidence and etiology of acute transverse myelitis in two major hospital districts in Southern Finland.

METHODS

We identified all patients with acute transverse myelitis admitted to Turku University Hospital and Päijät-Häme Central hospital during nine years. The two hospitals serve a catchment area of 673,000 people in Southern Finland. Acute transverse myelitis was diagnosed according to the 2002 Transverse Myelitis Consortium Working Group. Patient files were reviewed for details of the clinical presentation and disease outcome, for laboratory findings and for neuroimaging. Charts were re-evaluated after an average of 7.7 years for confirmation of the acute transverse myelitis etiology.

RESULTS

In total 63 patients fulfilled the Transverse Myelitis Consortium Working Group diagnostic criteria for acute transverse myelitis. The frequency of the condition was hence 1.04 cases/ 100,000 inhabitants/ year. In the studied cohort, 7/63 (11%) patients had idiopathic transverse myelitis after initial evaluation and in 4/63 (6.3%) patients the idiopathic transverse myelitis remained the final diagnosis after follow-up and re-evaluation. Of the disease-associated myelitis cases MS or clinically isolated syndrome was the largest group, explaining 41% of all myelitis cases. The mean follow-up time before a patient was diagnosed with MS was 1.7 ± 2.2 years. Other etiologies included acute disseminated encephalomyelitis (ADEM), neurosarcoidosis, neuromyelitis optica (NMO), systemic autoimmune diseases and infectious diseases.

CONCLUSIONS

In more than half of the acute transverse myelitis cases the final diagnosis is other than MS. Careful diagnostic work-up is needed for correct early treatment and best long-term outcome.

Epidemiology of pediatric multiple sclerosis: A systematic literature review and meta-analysis

BACKGROUND

Multiple sclerosis (MS) is a debilitating immune disease leading to demyelination, neurodegeneration, and chronic inflammation of the central nervous system. Pediatric MS is a rare form of the disease and effects approximately 2-10% of individuals with MS. Diagnostic criteria and therapies are continuously evolving, thus it is imperative to further understand the epidemiology and subsequently global and regional disease burden of pediatric MS. Our objective was to conduct a systematic literature review and meta-analysis to assess the incidence and prevalence of pediatric MS globally. Subgroup analyses were also conducted by region and diagnostic criteria used to ascertain cases.

METHODS

A systematic literature review was conducted using searches run in EMBASE and MEDLINE. A hand search was also conducted, and the bibliographies of any relevant articles were reviewed for any studies potentially not captured by the databases. A random effects model was used to combine epidemiological estimates across studies. Subgroup analyses by region and diagnostic criteria were performed in instances when three or more studies were available for analyses.

RESULTS

A total of 2,965 publications were identified, of which 187 were eligible for full-text screening. A total of 21 full-text articles met the eligibility criteria and were included for data extraction, with 18 studies included for meta-analysis. Regional epidemiologic estimates were obtained for North America, Europe, Middle East, and Asia. Country specific data was available for Canada, United States, Germany, Iceland, Netherlands, Sardinia, Slovenia, UAE/Abu Dhabi, Iran, Israel, Jordan, Kuwait, Tunisia, Taiwan, and Japan. Thirteen studies representing 12 countries reported incidence of pediatric MS. Overall incidence ranged from 0.05 to 2.85 and pooled global incidence was calculated to be 0.87 (95% CI: 0.35-1.40) per 100,000 individuals annually. Ten studies representing 10 countries reported on the prevalence of pediatric MS. Overall prevalence ranged from 0.69 to 26.92 per 100,000 individuals and pooled global prevalence was calculated to be 8.11 (95% CI: 2.28-13.93) per 100,000 people.

CONCLUSION

To our knowledge, this is the first meta-analysis conducted to provide pooled estimates of incidence and prevalence estimates of pediatric MS globally. In general, incidence estimates were similar across regions; however, prevalence was found to be more variable. Noticeable gaps in evidence include a lack of pediatric MS estimates from other large regions of the world such as Africa, South America, Russia, and Australia. Moreover, there is a need for more population-based studies using the most up to date diagnostic criteria.

Orbitofrontal involvement in a neuroCOVID-19 patient

Neurological manifestations of coronavirus disease 19 (COVID‐19) such as encephalitis and seizures have been reported increasingly, but our understanding of COVID‐19‐related brain injury is still limited. Herein we describe prefrontal involvement in a patient with COVID‐19 who presented prior anosmia, raising the question of a potential trans‐olfactory bulb brain invasion.

Childhood acute disseminated encephalomyelitis: an Egyptian pilot study

Describing the variable clinical features, laboratory findings, neuroimaging findings, and treatments given to children who presented with ADEM and following them up both clinically and radiologically. 21 patients were recruited: 14 new cases, and 7 old ones presenting over the preceding 5 years (retrospective review of existing data). 11 males and 10 females, with a mean age of 4.4 years ± 2.7 SD, were included. All new patients were subject to full history, examination and a panel of investigations including MRI of the brain. Treatment was given in the form of pulsed methyl prednisolone or intravenous immunoglobulin (IVIG), followed by clinical and radiological follow-up every 3 months as needed. 11 cases occurred in spring, 8 post vaccine, of which 5 were after oral polio vaccine (OPV). MRI was done for all 21 patients and was abnormal in all of them, CT was done in only 10 patients as was normal in 9. Hyponatremia was seen in 11 patients. All patients who received corticosteroids showed prompt improvement. 6 out of 10 patients who received IVIG first failed treatment. Of the 17 treated patients, 10 had no sequelae and 10 had total lesion resolution on MRI at 3 months, versus 1 and 0 patients, respectively, in the untreated group. We found a disproportionately large number of post vaccination cases, especially after OPV. The association of ADEM with hyponatremia needs further study. MRI is central to diagnosis. Outcome is much better with treatment with steroids being far superior to IVIG. Excess use of IVIG should be discouraged.

Clinical Characteristics and Disability Progression of Early- and Late-Onset Multiple Sclerosis Compared to Adult-Onset Multiple Sclerosis

Background: Compared to the adult onset of multiple sclerosis (AOMS), both early-onset (EOMS) and late-onset (LOMS) are much less frequent, but are often under- or misdiagnosed. The aims of the present study were: 1. To compare demographic and clinical features of individuals with EOMS, AOMS and LOMS, and 2. To identify predictors for disability progression from relapsing remitting MS (RRMS) to secondary progressive MS (SPMS). Method: Data were taken from the Isfahan Hakim MS database. Cases were classified as EOMS (MS onset ≤18 years), LOMS (MS onset >50 years) and AOMS (MS >18 and ≤50 years). Patients’ demographic and clinical (initial symptoms; course of disease; disease patterns from MRI; disease progress) information were gathered and assessed. Kaplan–Meier and Cox proportional hazard regressions were conducted to determine differences between the three groups in the time lapse in conversion from relapsing remitting MS to secondary progressive MS. Results: A total of 2627 MS cases were assessed; of these 127 were EOMS, 84 LOMS and 2416 AOMS. The mean age of those with EOMS was 14.5 years; key symptoms were visual impairments, brain stem dysfunction, sensory disturbances and motor dysfunctions. On average, 24.6 years after disease onset, 14.2% with relapsing remitting MS (RRMS) were diagnosed with secondary progressive MS (SPMS). The key predictor variable was a higher Expanded Disability Status Scale (EDSS) score at disease onset. Compared to individuals with AOMS and LOMS, those with EOMS more often had one or two relapses in the first two years, and more often gadolinium-enhancing brain lesions. For individuals with AOMS, mean age was 29.4 years; key symptoms were sensory disturbances, motor dysfunctions and visual impairments. On average, 20.5 years after disease onset, 15.6% with RRMS progressed to SPMS. The key predictors at disease onset were: a higher EDSS score, younger age, a shorter inter-attack interval and spinal lesions. Compared to individuals with EOMS and LOMS, individuals with AOMS more often had either no or three and more relapses in the first two years. For individuals with LOMS, mean age was 53.8 years; key symptoms were motor dysfunctions, sensory disturbances and visual impairments. On average, 14 years after disease onset, 25.3% with RRMS switched to an SPMS. The key predictors at disease onset were: occurrence of spinal lesions and spinal gadolinium-enhancement. Compared to individuals with EOMS and AOMS, individuals with LOMS more often had no relapses in the first two years, and higher EDSS scores at disease onset and at follow-up. Conclusion: Among a large sample of MS sufferers, cases with early onset and late onset are observable. Individuals with early, adult and late onset MS each display distinct features which should be taken in consideration in their treatment.

Pediatric multiple sclerosis: from clinical basis to imaging spectrum and differential diagnosis

Pediatric multiple sclerosis (MS) deserves special attention because of its impact on cognitive function and development. Although knowledge regarding pediatric MS has rapidly increased, understanding the peculiarities of this population remains crucial for disease management. There is limited expertise about the efficacy and safety of current disease-modifying agents. Although pathophysiology is not entirely understood, some risk factors and immunological features have been described and are discussed herein. While the revised International Pediatric MS Study Group diagnostic criteria have improved the accuracy of diagnosis, the recently revised McDonald criteria also offer some new insights into the pediatric population. It is fundamental that radiologists have strong knowledge about the vast spectrum of demyelinating disorders that can occur in childhood to ensure appropriate diagnosis and provide early treatment.

Neuro-ophthalmological manifestations as complication of an infection with Mycoplasma pneumoniae and subsequent development of disseminated acute encephalitis

The purpose of this article is to describe two paediatric neuro-ophthalmological clinical cases caused by a systemic infection due to Mycoplasma pneumoniae (M. pneumoniae). The cases are two girls aged 14 and 12 seen in the Emergency Department: The first one had internuclear ophthalmoplegia and second with loss of vision and headache. They had no other neurological foci. Magnetic resonance imaging showed hyperintense plaques in both, suggestive of a demyelinating disease. One month later, the neuro-ophthalmological symptoms resolved, with normal follow-up magnetic resonance imagings. The diagnosis was acute disseminated encephalitis secondary to M. pneumoniae. The diagnosis was made using PCR (gold standard) and/or IgM in serology. It is important to think about this possible aetiology in cases of suggestive demyelinating disease. There is controversy about the role of antibiotics and on whether corticosteroids are contemplated. In conclusion, M. pneumoniae must be a differential diagnosis in acute neuro-ophthalmological disorders in children.

Clinical, Radiologic, and Prognostic Features of Myelitis Associated With Myelin Oligodendrocyte Glycoprotein Autoantibody

Importance

Recognizing the characteristics of myelin oligodendrocyte glycoprotein autoantibody (MOG-IgG) myelitis is essential for early accurate diagnosis and treatment.

Objective

To evaluate the clinical, radiologic, and prognostic features of MOG-IgG myelitis and compare with myelitis with aquaporin-4-IgG (AQP4-IgG) and multiple sclerosis (MS).

Design, Setting, and Participants

We retrospectively identified 199 MOG-IgG-positive Mayo Clinic patients from January 1, 2000, through December 31, 2017, through our neuroimmunology laboratory. Fifty-four patients met inclusion criteria of (1) clinical myelitis; (2) MOG-IgG positivity; and (3) medical records available. We excluded 145 patients without documented myelitis. Myelitis of AQP4-IgG (n = 46) and MS (n = 26) were used for comparison.

Main Outcomes and Measures

Outcome variables included modified Rankin score and need for gait aid. A neuroradiologist analyzed spine magnetic resonance imaging of patients with MOG-IgG and control patients blinded to diagnosis.

Results

Of 54 included patients with MOG-IgG myelitis, the median age was 25 years (range, 3-73 years) and 24 were women (44%). Isolated transverse myelitis was the initial manifestation in 29 patients (54%), and 10 (19%) were initially diagnosed as having viral/postviral acute flaccid myelitis. Cerebrospinal fluid-elevated oligoclonal bands occurred in 1 of 38 (3%). At final follow-up (median, 24 months; range, 2-120 months), 32 patients (59%) had developed 1 or more relapses of optic neuritis (n = 31); transverse myelitis (n = 7); or acute disseminated encephalomyelitis (n = 1). Clinical features favoring MOG-IgG myelitis vs AQP4-IgG or MS myelitis included prodromal symptoms and concurrent acute disseminated encephalomyelitis. Magnetic resonance imaging features favoring MOG-IgG over AQP4-IgG or MS myelitis were T2-signal abnormality confined to gray matter (sagittal line and axial H sign) and lack of enhancement. Longitudinally extensive T2 lesions were of similar frequency in MOG-IgG and AQP4-IgG myelitis (37 of 47 [79%] vs 28 of 34 [82%]; P = .52) but not found in MS. Multiple spinal cord lesions and conus involvement were more frequent with MOG-IgG than AQP4-IgG but not different from MS. Wheelchair dependence at myelitis nadir occurred in one-third of patients with MOG-IgG and AQP4-IgG but never with MS, although patients with MOG-IgG myelitis recovered better than those with AQP4-IgG.

Conclusions and Relevance

Myelitis is an early manifestation of MOG-IgG-related disease and may have a clinical phenotype of acute flaccid myelitis. We identified a variety of clinical and magnetic resonance imaging features that may help clinicians identify those at risk in whom MOG-IgG should be tested.

Understanding Childhood Neuroimmune Diseases of the Central Nervous System

Immune-mediated diseases of the central nervous system (CNS) in childhood are a heterogeneous group of rare conditions sharing the inflammatory involvement of the CNS. This review highlights the growing knowledge of childhood neuroimmune diseases that primarily affect the CNS, outlining the clinical and diagnostic features, the pathobiological mechanisms and genetics, current treatment options, and emerging challenges. The clinical spectrum of these conditions is increasingly expanded, and the underlying mechanisms of dysregulation of the immune system could vary widely. Cell-mediated and antibody-mediated disorders, infection-triggered and paraneoplastic conditions, and genetically defined mechanisms can occur in previously healthy children and can contribute to different stages of the disease. The careful evaluation of the clinical presentation and temporal course of symptoms, the specific neuroimaging and immunological findings, and the exclusion of alternative causes are mandatory in clinical practice for the syndromic diagnosis. A common feature of these conditions is that immunotherapeutic agents could modulate the clinical course and outcomes of the disease. Furthermore, specific symptomatic treatments and comprehensive multidisciplinary care are needed in the overall management. We focus on recent advances on immune-mediated demyelinating CNS disorders, autoimmune encephalitis, interferonopathies, and possible neuroimmune disorders as Rasmussen encephalitis. Better knowledge of these conditions could allow prompt diagnosis and targeted immunotherapy, to decrease morbidity and mortality as well as to improve clinical outcomes, reducing the burden of the disease due to possible long-term neuropsychiatric sequelae. Persisting controversies remain in the rigorous characterization of each specific clinical entity because of the relative rarity in children; moreover, in a large proportion of suspected neuroimmune diseases, the immune "signature" remains unidentified; treatment guidelines are mostly based on retrospective cohort studies and expert opinions; then advances in specific molecular therapies are required. In the future, a better characterization of specific immunological biomarkers may provide a useful understanding of the underlying pathobiological mechanisms of these conditions in order to individualize more tailored therapeutic options and paradigms. Multicenter collaborative research on homogeneous groups of patients who may undergo immunological studies and therapeutic trials could improve the characterization of the underlying mechanisms, the specific phenotypes, and tailored management.

Atypical Pediatric Demyelinating Diseases of the Central Nervous System

PURPOSE OF REVIEW

Pediatric central nervous system demyelinating diseases include multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and acute disseminated encephalomyelitis (ADEM). As diagnostic criteria become more inclusive, the risk of misdiagnosis of atypical demyelinating diseases of rheumatologic, infectious, and autoimmune etiology increases.

RECENT FINDINGS

We review mimics of multiple sclerosis, neuromyelitis optica spectrum disorder, and acute disseminated encephalomyelitis, including rheumatologic diseases: systemic lupus erythematosus and neuro-Behçet disease; infectious diseases: human immunodeficiency virus, progressive multifocal leukoencephalopathy, and subacute sclerosis panencephalitis; and autoimmune diseases including X-linked Charcot-Marie-Tooth disease, chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) and autoimmune glial fibrillary acidic protein (GFAP) encephalopathy. Atypical demyelinating disease may mimic classic neuroinflammatory diseases of the central nervous system. Imaging may meet criteria for a diagnosis of multiple sclerosis, or patients may present with optic neuritis and transverse myelitis consistent with neuromyelitis optica spectrum or myelin oligodendrocyte glycoprotein (MOG) antibody disorders. Through careful history-taking and review of atypical MRI findings, we may avoid misdiagnosis and mistreatment.

Determinants of quality of life in pediatric- and adult-onset multiple sclerosis

Objective

To evaluate quality of life (QoL), measured by the EQ-5D, in adults with pediatric-onset multiple sclerosis (POMS) or adult-onset multiple sclerosis (AOMS) and explore determinants of QoL in both groups.

Methods

Data were collected from the nationwide Swedish multiple sclerosis (MS) registry. Demographic characteristics, EQ-5D-3 level, Multiple Sclerosis Impact Scale (MSIS-29) score, Expanded Disability Status Scale (EDSS) score, Symbol Digit Modalities Test score, relapses, and disease-modifying therapy (DMT) exposure were collected on an approximately annual basis (2011–2019). Patients with definite MS with ≥2 EQ-5D measurements collected between ages 18 and 50 were included. The principal outcome was the EQ-5D visual analogue scale (EQ-VAS) score. Linear mixed models compared all available EQ-VAS scores between patients with POMS and patients with AOMS and determinants of EQ-VAS among patients with POMS and patients with AOMS (assessed separately).

Results

A total of 5,094 persons met inclusion criteria: 354 (6.9%) had POMS. A total of 21,357 unique EQ-5D scores were recorded. Most participants were female (70.0%) with a relapsing-onset disease course (98.1%). There was no difference in EQ-VAS scores between patients with POMS and patients with AOMS following adjustment for confounders (β-coefficient for patients with POMS vs patients with AOMS [reference]: 0.99; 95% confidence interval −0.89 to 2.87). Experiencing a relapse, severe neurologic disability (EDSS ≥6.0 vs <3.0), and higher MSIS-29 psychological score were consistently associated with lower QoL, while higher information processing efficiency and exposure to first-line DMTs were associated with higher QoL scores in both groups.

Conclusions

There were no differences in QoL between patients with POMS and patients with AOMS in adulthood. Findings provide support for a focus on reducing neurologic disability and improving psychological status as approaches to potentially improve the QoL of persons with MS.

Acute Disseminated Encephalomyelitis in Children: An Updated Review Based on Current Diagnostic Criteria

Acute disseminated encephalomyelitis is an inflammatory disorder of the central nervous system. Uniform diagnostic criteria for acute disseminated encephalomyelitis did not exist until publication of expert-defined consensus definitions by the International Pediatric Multiple Sclerosis Society Group in 2007, with updates in 2013. In the expanding field of pediatric neuroimmunology, consistent diagnostic criteria are essential to correctly categorize patients as increasing information regarding prognosis and management becomes available. Scientific literature is relatively lacking in review articles on International Pediatric Multiple Sclerosis Society Group-defined acute disseminated encephalomyelitis. This review focuses primarily on references applying the International Pediatric Multiple Sclerosis Society Group criteria for acute disseminated encephalomyelitis presenting specific, up-to-date, and translatable information regarding the epidemiology, pathophysiology, clinical features, diagnosis, management, and prognosis of acute disseminated encephalomyelitis in the pediatric population.

Association of Obesity With Multiple Sclerosis Risk and Response to First-line Disease Modifying Drugs in Children

Importance

Obesity reportedly increases the risk of pediatric multiple sclerosis (MS), but little is known about its association with disease course.

Objective

To investigate the association of obesity with pediatric MS risk and with first-line therapy response among children with MS.

Design, Setting, and Participants

This single-center retrospective study used the medical records and database at the Center for MS in Childhood and Adolescence, Göttingen, Germany. The study included 453 patients with relapsing-remitting pediatric MS and body mass index (BMI) measurement taken within 6 months of diagnosis. Onset of the disease occurred between April 28, 1990, and June 26, 2016, and the mean disease duration was 38.4 months. Data were collected from July 14, 2016, to December 18, 2017.

Main Outcomes and Measures

Data on BMIs were stratified by sex and age using German BMI references and compared with the BMI data of 14 747 controls from a nationwide child health survey for odds ratio (OR) estimates. Baseline magnetic resonance imaging findings, intervals between first and second MS attacks, annualized relapse rates before and during treatment with interferon beta-1a or -1b and glatiramer acetate, frequency of second-line treatment, and Expanded Disability Status Scale (EDSS) scores were compared between nonoverweight (BMI≤90th percentile), overweight (BMI>90th-97th percentile), and obese (BMI>97th percentile) patients.

Results

In total, 453 patients with pediatric MS were included, of whom 306 (67.5%) were female, and the mean (SD) age at diagnosis was 13.7 (2.7) years. At diagnosis, 126 patients (27.8%) were overweight or obese, with obesity associated with statistically significant twofold odds of MS in both sexes (girls OR, 2.19; 95% CI, 1.5-3.1; P < .001 vs boys OR, 2.14; 95% CI, 1.3-3.5; P = .003). Obese patients, compared with nonoverweight patients, had statistically significantly more relapses on first-line treatment with interferon beta and glatiramer acetate (ARR, 1.29 vs 0.72; P < .001) and a higher rate of second-line treatment (21 [56.8%] of 37 vs 48 [38.7%] of 124; P = .06). Baseline neuroimaging, interval between first and second MS attacks, pretreatment relapses, and EDSS progression scores were not correlated with BMI.

Conclusions and Relevance

In this study, increased pediatric MS risk appeared to be associated with obesity, and obese patients did not respond well to first-line medications; altered pharmacokinetics appeared to be most likely factors in treatment response, suggesting that achieving healthy weight or adjusting the dose according to BMI could improve therapy response.

A Review of Available Treatments, Clinical Evidence, and Guidelines for Diagnosis and Treatment of Pediatric Multiple Sclerosis in the United States

Pediatric multiple sclerosis is associated with challenges in prompt diagnosis and uncertainty regarding optimal treatment. This review aimed to identify treatment guidelines or consensus statements for pediatric patients with multiple sclerosis, US Food and Drug Administration (FDA)-approved treatment options for pediatric multiple sclerosis, and any randomized controlled trials and observational studies examining available pharmacologic treatments in the pediatric multiple sclerosis population. Literature searches were performed in MEDLINE (1946-2016), EMBASE (1974-2016), and the Cochrane Central Register of Controlled Trials to identify treatment guidelines or consensus statements, pediatric multiple sclerosis treatment approvals, and randomized controlled trials and observation studies that examine the safety and effectiveness of available disease-modifying therapies. Only 3 consensus statements provided recommendations for pharmacologic treatments for children, all 3 published before the most recent revisions of the pediatric multiple sclerosis diagnostic guidelines. Despite the changes to the clinical landscape of pediatric multiple sclerosis with the introduction of diagnostic guidelines, fingolimod is the only FDA-approved treatment for pediatric multiple sclerosis in the United States. The effectiveness and safety of other disease-modifying therapies suggested by consensus statements have been reported in relatively small prospective and retrospective observational studies. Clinical evidence from a recently completed randomized controlled trial and future global registries can inform treatment decisions for the pediatric multiple sclerosis population.

Pediatric multiple sclerosis and its familial recurrence: A population based study (1999-2017)

BACKGROUND

The Pediatric onset multiple sclerosis (POMS) prevalence is increasing worldwide accounting for around 3 to 10% of MS cases. The risk of POMS is supposed to reflect a complex interaction between environmental and genetic risk factors that may occur during the childhood, adolescent, or post-pubertal years.

OBJECTIVE

The present study aimed at estimating the prevalence of POMS and assessing the epidemiology of familial recurrence of POMS in Tehran.

METHOD

A retrospective population based cross-sectional study was designed from 1999 to 2017. The baseline characteristic information was collected from MS patient's ≤18 years old (y/o). Pearson's chi-square test and logistic regression were used to analyze the relationship among variables and estimate the odds ratio (OR) via SPSS software, version 23.

RESULTS

A total of 1937 POMS patients (77.80% female and 22.20% male patients) participated in the study. The point prevalence of POMS was 16.20 per 100,000 populations in 2017. Mean age at disease onset was 15.96 ± 2.28 y/o. The female to male ratio was 2.02:1 in pre-pubertal cases (3-12 y/o), but it increased to 3.69:1 in 13-18 y/o age groups (P value = 0.001, OR = 1.82; 95% CI = 1.27-2.26). There were 288 (14.9%) cases with positive familial history of MS. The strongest association between MS risk and positive familial history was observed in second degree relatives who presented MS (P value = 0.046, OR = 1.74; 95%CI = 1.01-3.01). A significant association was observed among maternal second degree relatives with POMS (P value = 0.018, OR = 2.27; 95%CI = 1.15-4.47).

CONCLUSION

In comparison to other large studies, the prevalence of POMS was high in the data collected from Tehran. POMS risk is higher among females and the sex ratio increases after puberty. We found a significant association between POMS risk and familial history in maternal second degree relatives. Further studies of POMS epidemiology might yield greater understanding of the natural history of this disease.

Pediatric acquired demyelinating syndrome (ADS) in inpatient hospital settings: The hospitalization rate, costs, and outcomes in the US

BACKGROUND

Although relatively rare among pediatric patients, acquired demyelinating syndromes of the central nervous system (ADS) is a potentially disabling condition that warrants hospitalization and long-term follow-up. As such, a better understanding of the epidemiology and hospital utilization for this condition could provide critical information for health care planning and resource allocation.

OBJECTIVE

To evaluate the trends of hospital utilization and resource use associated with pediatric ADS in the US.

METHOD

We conducted a serial cross-sectional trend analysis with complex sampling and weighting using nationally representative hospital discharge records, from the Kids´ Inpatient Database (KID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality coded with International Classification of Diseases (Healthcare Cost and Utilization Project (HCUP) 2018), Ninth Revision (ICD-9-CM) for the years 2003, 2006, 2009, and 2012. We also conducted a cross-sectional study for the KID2016 dataset coded with ICD10-CM to estimate the pediatric ADS-related hospital utilization for the year. EXCLUDING TRANSFERRING DISCHARGES: we evaluated the discharge records for those aged 0 to 19 years diagnosed with any of ADS of central nervous systems including multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), acute disseminated encephalomyelitis (ADEM), optic neuritis (ON), transverse myelitis (TM) and demyelinating disease not specified (DDNS). For the trend analysis, we used variance-weighted regression and Poisson regression for the annual hospitalization rate, total hospital charges and hospital days associated with the ADS hospitalizations for the year 2003 to 2012.

RESULTS

We estimated a total of 1,292 ADS-related hospitalizations (95%CI: 1127-1,458) in 2003, 2104 hospitalizations (95%CI: 1823-2385) in 2006, 2851 hospitalizations (95%CI: 2499-3203) in 2009, and 3501 hospitalizations (95%CI: 3058-3945) in 2012 among those aged 19 years or younger with diagnoses of ADS. There was an increase in the proportion of the inpatient hospital cost attributed to ADS from 0.06% in 2003 to 0.20% in 2012. The annual hospitalization rates relative to pediatric ADS were 1.59/100,000 (95%CI: 1.51-1.68) in 2003 and 4.21/100,000 (95%CI: 4.07-4.35) in 2012. In the cross-sectional analysis for the year 2016 coded by ICD10-CM, the number of pediatric ADS related hospitalizations were 4,568, constituting 0.30% of the total pediatric hospitalization cost. The annual hospitalization rate for the year 2016 was estimated to be 5.51/100,000.

CONCLUSION

Hospital utilization by pediatric patients with ADS increased during the period 2003 through 2012. The cross-sectional analysis for the year 2016 indicated that the trend could be ongoing, although the direct comparison was not feasible due to the changes in the coding system of the dataset from ICD9-CM to ICD10-CM. Although relatively rare, pediatric ADS warrant long-term follow-ups and hospitalizations, impacting the developmental trajectory of the affected children and the lives of their family members. Th potentially increasing trend of pediatric ADS hospital utilization should be acknowledged when allocating and planning future resources and supporting programs.

Differential Diagnosis of Pediatric Multiple Sclerosis

The differential diagnosis of pediatric multiple sclerosis (MS) can be broad and pose diagnostic challenges, particularly at initial presentation. Among demyelinating entities, neuromyelitis optica spectrum disorders (NMOSD), myelin oligodendrocyte glycoprotein antibodies (MOG-ab) associated disorders, and acute disseminated encephalomyelitis (ADEM) are now well-known as unique disease processes and yet continue to overlap with MS in regards to clinical presentation and imaging. In non-inflammatory entities, such as metabolic disorders and leukodystrophies, an erroneous diagnosis of MS can be made even while applying appropriate diagnostic criteria. Knowing the epidemiology, typical clinical presentation, diagnostic criteria, and ancillary test results in each disease, can aid in making the correct diagnosis by contrasting these features with those of pediatric MS. Determining the correct diagnosis early, allows for efficient and effective treatment as well as appropriate prognostication.

Long-term disability progression of pediatric-onset multiple sclerosis

OBJECTIVE

To evaluate long-term disability progression in pediatric-onset multiple sclerosis (POMS) and compare to adult-onset multiple sclerosis (AOMS).

METHODS

This was a retrospective cohort study using prospectively collected clinical information from the Swedish MS Registry. Clinical features were compared and Kaplan-Meier and Cox proportional hazards regression were used to assess the risk of reaching sustained Expanded Disability Status Scale (EDSS) 3, 4, and 6 in POMS (multiple sclerosis [MS] onset <18 years) and AOMS (MS onset ≥18 years).

RESULTS

A total of 12,482 persons were included; 549 (4.4%) were classified as POMS. The POMS cohort took longer to reach all 3 disability milestones from their MS onset, but did so at a younger age than the AOMS cohort. Primary progressive course (hazard ratio [HR] 4.63; 95% confidence interval [CI] 1.46-14.7), higher relapse rate in the first 5 years of disease (HR 5.35; 95% CI 3.37-8.49), and complete remission from the initial relapse (HR 0.41; 95% CI 0.18-0.94) were associated with an altered risk of progression to EDSS 4 among POMS cases. The same pattern emerged for the risk of reaching EDSS 3 and 6.

CONCLUSIONS

Patients with pediatric-onset MS follow a distinctive clinical course, which should be considered in the treatment and management of the disease.

An interesting case of acute disseminated encephalomyelitis following E. coli infection

Acute disseminated encephalomyelitis (ADEM) is a rare inflammatory demyelinating disease of central nervous system (CNS), characterized by multifocal white matter involvement with neurological deficits and accompanied by encephalopathy. ADEM is thought to be caused by autoimmune etiology. CNS autoantigens are produced by molecular mimicry triggered by an environmental stimulus, mostly infection (viral/bacterial) or post vaccination, in genetically susceptible individuals. ADEM is sometimes referred to as post/para-infectious or post-immunization ADEM. ADEM is characterized by multifocal neurological signs and occasionally it rapidly progresses to coma. Magnetic resonance imaging (MRI) is used to confirm the diagnosis. The treatment is based on intravenous high-dose methylprednisolone, which usually leads to a rapid improvement. Recently, the use of intravenous immunoglobulins and plasma exchange (PLEX) has also been suggested. We report a case of a 6-year-old girl who was admitted for urinary tract infection but developed neurological complications which was treated successfully.

Diagnosing autoimmune encephalitis based on clinical features and autoantibody findings

INTRODUCTION

Autoimmune encephalitides have been accepted as a reproducible and treatable new group of diseases. At present, there is concern that such diagnoses might be made too liberally. Areas covered: This article suggests how to make valid diagnoses. They should consist of three elements: the clinical syndrome, the associated antibody and the presumed cause or predisposition. Recently, an international consortium published formal clinical criteria for autoimmune encephalitides to enable diagnoses even if antibody testing is not (immediately) available and to prevent overinterpretation of questionable antibody results. Antibody testing has greatly benefitted from the introduction of cell-based assays for the demonstration of antibodies against surface antigens. Paraneoplastic or post-infectious situations, side effects of tumor therapies or genetic predispositions help to explain why a patient develops autoimmune encephalitis. Expert opinion: With the application of this three-fold diagnostic system, clinicians can counsel patients regarding therapy and prognosis, while researchers can form meaningful patient cohorts. An operationalization of criteria would be advantageous.

Temporal Trends of Pediatric Hospitalizations with Acute Disseminated Encephalomyelitis in the United States: An Analysis from 2006 to 2014 using National Inpatient Sample

OBJECTIVE

To determine the temporal trends in the epidemiology of acute disseminated encephalomyelitis (ADEM) and hospitalization outcomes in the US from 2006 through 2014.

STUDY DESIGN

Pediatric (≤18 years of age) hospitalizations with ADEM discharge diagnosis were identified from the National (Nationwide) Inpatient Sample (NIS) for years 2006 through 2014. Trends in the incidence of ADEM with respect to age, sex, race, and region were examined. Outcomes of ADEM in terms of mortality, length of stay (LOS), cost of hospitalization, and seasonal variation were analyzed. NIS includes sampling weight. These weights were used to generate national estimates. P value  of < .05 was considered significant.

RESULTS

Overall incidence of ADEM associated pediatric hospitalizations from 2006 through 2014 was 0.5 per 100 000 population. Between 2006 through 2008 and 2012 through 2014, the incidence of ADEM increased from 0.4 to 0.6 per 100 000 (P-trend <.001). Black and Hispanic children had a significantly increased incidence of ADEM during the study period (0.2-0.5 per 100 000 population). There was no sex preponderance and 67% of ADEM hospitalizations were in patients <9 years old. From 2006 through 2008 to 2012 through 2014 (1.1%-1.5%; P-trend 0.07) and median LOS (4.8-5.5 days; P_trend = .3) remained stable. However, median inflation adjusted cost increased from $11 594 in 2006 through 2008 to $16 193 in 2012 through 2014 (P_trend = .002).

CONCLUSION

In this large nationwide cohort of ADEM hospitalizations, the incidence of ADEM increased during the study period. Mortality and LOS have remained stable over time, but inflation adjusted cost of hospitalizations increased.

SUCCESSFUL TREATMENT OF ACUTE DISSEMINATED ENCEPHALOMYELITIS (ADEM) BY PROMPT USAGE OF IMMUNOGLOBULINS - CASE REPORT AND REVIEW OF THE LITERATURE

Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system that usually affects children and young adults. It most commonly has a monophasic course, although relapses are reported. Clinical presentation of the disease includes encephalopathy and multifocal neurological deficits. There are no established reliable criteria for diagnosis of ADEM and sometimes it is difficult to distinguish it from first attack of multiple sclerosis, especially in adults. The diagnosis of ADEM is based on clinical, radiological and laboratory findings. In the treatment of ADEM, high doses of corticosteroids, plasmapheresis and immunoglobulins are used. We report a case of a young adult female patient with ADEM who fully recovered after prompt administration of high dose methylprednisolone and immunoglobulins.

Cognitive Functioning in Patients with Pediatric-Onset Multiple Sclerosis, an Updated Review and Future Focus

Pediatric-onset multiple sclerosis (POMS) is relatively rare, but as technology and neuroimaging advance, an increasing number of cases are identified, and our understanding of how multiple sclerosis (MS) impacts the developing brain improves. There are consistent findings in the literature highlighting the impact of MS and other demyelinating diseases on cognitive functioning and cognitive development. We also have a better understanding of how POMS impacts psychosocial functioning and functional outcomes in daily living. This paper hopes to review findings associated with cognitive and psychosocial functioning in patients with POMS, as well as explore more recent advances in the field and how they relate to cognitive and psychosocial outcomes. We also discuss the ongoing need for future studies with a focus on better understanding deficits and disease correlates, but also preventative measures and potential rehabilitation.

Delayed appearance of transient hyperintensity foci on T1-weighted magnetic resonance imaging in acute disseminated encephalomyelitis

PURPOSE

To evaluate the frequency, characteristics, and clinical significance of transient hyperintensity foci on T1-weighted images (T1WI) in acute disseminated encephalomyelitis (ADEM).

MATERIALS AND METHODS

Patients diagnosed with ADEM underwent MR studies at the time of disease onset and every 3 months or more often thereafter. The frequency and appearance timing of abnormal signals including T1WI and their morphological characteristics were evaluated. Relations between patient symptoms and abnormal signals on MRI were also evaluated.

RESULTS

Five ADEM patients were included in this study. Linear (n = 2) or nodular (n = 1) T1-hyperintensity foci appeared in 3 patients (60%, 3/5). Locations of T1-hyperintensity foci were both cortical/subcortical region and basal ganglia (n = 1), subcortical region alone (n = 1), and internal capsule (n = 1). Those T1-hyperintensity foci were located within the T2-weighted image (T2WI) and fluid-attenuated inversion recovery (FLAIR) hyperintensity foci on initial MRI. Some T1-hyperintensity foci also showed hyperintensity on diffusion-weighted image (DWI) and contrast enhancement. T1-hyperintensity appeared at 14-43 days (median, 28 days), and disappeared in 2 patients at 91 days and 627 days after disease onset. There were no neurological sequelae remained in any patients.

CONCLUSION

T1-hyperintensity foci is not a rare finding (60%) and it can be observed after improvement in symptoms in ADEM.

Vaccination-associated acute disseminated encephalomyelitis

While the basic definition of vaccination-associated acute disseminated encephalomyelitis (ADEM) is relatively clear and easily understandable, it is often difficult to diagnose ADEM based on clinical findings alone. ADEM is actually a heterogeneous clinical syndrome that can be approximately characterized by encephalomyelitis with multiple inflammatory demyelination, autoimmune causes, and relationship with a preceding infection or vaccination. The differential diagnosis of ADEM should exclude the possibility of infectious or other autoimmune encephalitis. The occurrence of vaccination-associated ADEM is influenced by several factors including the health and ethnic status of the vaccinated individual, vaccine components, and environment. Cases suspected of vaccination-associated ADEM should be analyzed cautiously from multi-disciplinary perspectives.

Predictors of Evolution Into Multiple Sclerosis After a First Acute Demyelinating Syndrome in Children and Adolescents

Background/Objective: The aim of the study was to estimate the rate of evolution or for multiple sclerosis (MS), after a first acute demyelinating event (ADE) in pediatric patients, and to investigate the variables that predict this evolution.

Methods: We retrospectively evaluated the clinical and neuroradiological features of children who presented a first ADE between January 2005 and April 2017. All patients included underwent a baseline MRI, a cerebrospinal fluid and blood analysis, including virological examinations. The evolution into MS was determined by the 2013 International Pediatric Multiple Sclerosis Study Group (IPMSSG) criteria. Clinical and radiological features predictive of MS were determined using multivariate analyses.

Results: Ninety-one patients were selected (mean age at onset: 10.11 ± 4.6). After a mean follow-up of 5.6 ± 2.3 years, 35% of patients' conditions evolved to MS. In the logistic multivariate analysis of clinical and laboratory data, the best predictors of evolution into MS were: the presence of oligoclonal bands in CSF (p < 0.001), past infection with EBV (p < 0.001), periventricular lesions (p < 0.001), hypointense lesions on T1 (p < 0.001), and lesions of the corpus callosum (p < 0.001) including Dawson fingers (p < 0.001).

Conclusion: Our findings suggest that a pattern of neuroimaging and laboratory findings may help to distinguish between, at clinical onset, children with a monophasic syndrome (clinically isolated syndrome or acute disseminated encephalomyelitis) from those who will develop MS.

Detection of aquaporin-4 antibodies for patients with CNS inflammatory demyelinating diseases other than typical MS in Lithuania

OBJECTIVES

Neuromyelitis optica (NMO) is frequently associated with aquaporin-4 autoantibodies (AQP4-Ab); however, studies of NMO in Lithuania are lacking. Therefore, the main objective of our study is to assess positivity for AQP4-Ab in patients presenting with inflammatory demyelinating central nervous system (CNS) diseases other than typical multiple sclerosis (MS) in Lithuania.

MATERIALS AND METHODS

Data were collected from the two largest University hospitals in Lithuania. During the study period, there were 121 newly diagnosed typical MS cases, which were included in the MS registry database. After excluding these typical MS cases, we analyzed the remaining 29 cases of other CNS inflammatory demyelinating diseases, including atypical MS (n = 14), acute transverse myelitis, TM (n = 8), acute disseminated encephalomyelitis, ADEM (n = 3), clinically isolated syndrome, CIS (n = 2), atypical optic neuritis, ON (n = 1), and NMO (n = 1). We assessed positivity for AQP4-Ab for the 29 patients and evaluated clinical, laboratory, and instrumental differences between AQP4-Ab seropositive and AQP4-Ab seronegative patient groups.

RESULTS

AQP4-Ab test was positive for three (10.3%) patients in our study, with initial diagnoses of atypical MS (n = 2) and ADEM (n = 1). One study patient was AQP4-Ab negative despite being previously clinically diagnosed with NMO. There were no significant clinical, laboratory, or instrumental differences between the groups of AQP4-Ab positive (3 [10.3%]) and negative (26 [89.7%]) patients.

CONCLUSIONS

AQP4-Ab test was positive for one-tenth of patients with CNS inflammatory demyelinating diseases other than typical MS in our study. AQP4-Ab testing is highly recommended for patients presenting with not only TM and ON but also an atypical course of MS and ADEM.

Implications of the International Paediatric Multiple Sclerosis Study Group consensus criteria for paediatric acute disseminated encephalomyelitis: a nationwide validation study

AIM

The International Paediatric Multiple Sclerosis Study Group (IPMSSG) has proposed criteria for acute disseminated encephalomyelitis (ADEM) not evaluated in clinical practice. Our objective was to assess epidemiological implications of the IPMSSG criteria for ADEM in a cohort study using prospectively collected data.

METHOD

We identified all diagnosed cases of ADEM in Denmark between 2008 and 2015 from the Danish National Patient Register by International Classification of Diseases 10 codes assigned to acute demyelinating episodes, and we reviewed all medical records to validate ADEM.

RESULTS

We found 52 children up to the age of 18 years with a verified clinical diagnosis of ADEM (incidence rate 0.54/100 000 person-years; all had abnormal brain magnetic resonance imaging). Only 18 (35%) fulfilled the IPMSSG criteria regarding encephalopathy and polyfocal neurological deficits. Among all 52 children with ADEM, 33 per cent had clinical sequelae after a median follow-up of 4 years 6 months (range: 10mo-8y 3mo). Surprisingly, none progressed to multiphasic ADEM or multiple sclerosis, but median age at end of follow-up was only 10 years 9 months (range: 2y-24y 3mo).

INTERPRETATION

Among 52 children with ADEM, none converted to multiphasic ADEM or multiple sclerosis (median follow-up: 4y 6mo; range: 10mo-8y 3mo). Applying the IPMSSG criteria to all children with a diagnosis of ADEM leaves 65 per cent of the cases without a diagnosis and lowers the incidence rate of paediatric ADEM.

WHAT THIS PAPER ADDS

The incidence of paediatric acute disseminated encephalomyelitis (ADEM) was 0.54 per 100 000 person-years in children younger than 18 years. Only 35 per cent of children with ADEM fulfilled the International Paediatric Study Group consensus criteria. ADEM in clinical practice was primarily based on magnetic resonance imaging findings. Paediatric neurologists diagnosed ADEM in the absence of encephalopathy. None of the children with ADEM progressed to multiple sclerosis/multiphasic ADEM during follow-up.

A Scoping Review of Modifiable Risk Factors in Pediatric Onset Multiple Sclerosis: Building for the Future

Knowledge of the effect of modifiable lifestyle factors in the pediatric multiple sclerosis (MS) population is limited. We therefore conducted a scoping review, following the framework provided by Arksey and O'Malley. Four databases were searched for pediatric MS and modifiable lifestyle factors using index terms and keywords, from inception to May 2018. All quantitative and qualitative primary articles were included and limited to English and full text. Of the 7202 articles identified and screened, 25 full-text articles were relevant to our objective and were included. These articles focused on diet obesity, physical activity, and sleep. In cross-sectional analyses, these lifestyle factors were associated with increased risk of pediatric onset MS (POMS), and increased disease activity. Diet, particularly vitamin D and vegetable intake, was associated with reduced relapse rate. Obesity was linked to increased risk of POMS, and physical activity was associated with reduced relapse rate and sleep/rest fatigue. Thus, available studies of lifestyle related outcomes in pediatric MS suggest specific lifestyle related factors, including obesity, higher vitamin D levels, and higher physical activity may associate with lower disease burden in POMS. Studies reviewed are limited by their observational designs. Future studies with longitudinal and experimental designs may further clarify the role of modifiable lifestyle factors in this population.

Incidence and prevalence of MS in children

Objective

To validate a case definition of multiple sclerosis (MS) in the pediatric population using administrative (health claims) data, and to estimate the incidence and prevalence of MS in the pediatric population for Ontario, Canada.

Methods

We used population-based administrative data to identify persons aged ≤18 years with MS. We assessed the performance of multiple administrative case definitions using a clinical reference cohort including children with MS, children with monophasic demyelinating syndromes, and healthy children; we report sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). We applied 2 preferred case definitions to estimate the incidence and prevalence of MS from 2003 to 2014.

Results

The Canadian Chronic Disease Surveillance System definition of ≥1 hospitalization or ≥5 physician claims for MS within 2 years had a sensitivity of 81.1%, specificity of 100%, PPV of 100%, and NPV of 86%. The Marrie definition of ≥3 hospital or physician claims for MS ever had a sensitivity of 89.2%, specificity of 100%, PPV of 100%, and NPV of 91.5%. Depending on the administrative case definition used, in 2014, the annual age-standardized annual incidence of MS in the pediatric population ranged from 0.99 to 1.24 per 100,000 population, and the age-standardized prevalence ranged from 4.03 to 6.8 per 100,000 population. The prevalence of MS rose over time.

Conclusion

Administrative data provide a feasible, valid means of estimating the incidence and prevalence of MS in the pediatric population. MS prevalence in the Ontario pediatric population is among the highest reported in pediatric populations worldwide.

Rituximab was effective for acute disseminated encephalomyelitis followed by recurrent optic neuritis with anti-myelin oligodendrocyte glycoprotein antibodies

BACKGROUND

The effect of rituximab on acute disseminated encephalomyelitis (ADEM) followed by recurrent optic neuritis (ON) is not yet known.

PATIENT

We are reporting the case of a 4-year-old Japanese girl who was diagnosed with anti-myelin oligodendrocyte glycoprotein (MOG) antibody positive ADEM followed by recurrent ON. She developed altered mental status, left facial paralysis, left paresis, and experienced three episodes of ON. She was treated with rituximab and azathioprine (AZA) as prevention for recurrent ON. She relapsed under treatment with AZA when CD19 cells reappeared 6 months after the first rituximab infusion. However, she has not relapsed since her CD19 count was reduced and kept low with rituximab infusion.

CONCLUSIONS

It is conceivable that anti-MOG antibodies are involved in the pathology of "ADEM followed by recurrent ON," and that the early introduction of rituximab, which is involved in the suppression of antibody production and has effects on CD20 T lymphocytes, may be a feasible treatment for ON. Due to the small number of patients, additional reports on prospectively followed patients are needed.

Pediatric Multiple Sclerosis: From Recognition to Practical Clinical Management

Pediatric-onset multiple sclerosis (MS) is a rare but increasingly recognized condition that both parallels and diverges from adult-onset MS. Exposure to key risk determinants for MS disease pathogenesis may occur during childhood. The diagnosis of pediatric MS can be challenging due to potential for atypical presentations and a broad differential diagnosis. MS disease-modifying therapies have not been rigorously studied in children and raise difficult questions on how to manage a chronic inflammatory neurologic disease in a population of patients with developing central nervous and immune systems.

Acute Intermittent Porphyria: A Rare Cause of Acute Disseminated Encephalomyelitis

Acute disseminated encephalomyelitis (ADEM) is a demyelinating disease of the central nervous system (CNS) with no distinct etiology but implications include infections and commonly administered vaccinations. In this case report, we present the case of ADEM in a young female who was subsequently diagnosed with acute intermittent porphyria (AIP) that was the instigator of the initial CNS assault. Our case highlights the peculiar presentation of ADEM which can present as a diagnostic challenge and brings forth AIP as a new and previously unknown affiliate of this rare CNS disease. We also discuss the pathophysiology, diagnostic criteria, and subsequent treatment options for this rare clinical entity.

Incidence and outcome of acquired demyelinating syndromes in Dutch children: update of a nationwide and prospective study

INTRODUCTION

Acquired demyelinating syndromes (ADS) are immune-mediated demyelinating disorders of the central nervous system in children. A nationwide, multicentre and prospective cohort study was initiated in the Netherlands in 2006, with a reported ADS incidence of 0.66/100,000 per year and MS incidence of 0.15/100,000 per year in the period between 2007 and 2010. In this study, we provide an update on the incidence and the long-term follow-up of ADS in the Netherlands.

METHODS

Children < 18 years with a first attack of demyelination were included consecutively from January 2006 to December 2016. Diagnoses were based on the International Paediatric MS study group consensus criteria. Outcome data were collected by neurological and neuropsychological assessments, and telephone call assessments.

RESULTS

Between 2011 and 2016, 55/165 of the ADS patients were diagnosed with MS (33%). This resulted in an increased ADS and MS incidence of 0.80/100,000 per year and 0.26/100,000 per year, respectively. Since 2006 a total of 243 ADS patients have been included. During follow-up (median 55 months, IQR 28-84), 137 patients were diagnosed with monophasic disease (56%), 89 with MS (37%) and 17 with multiphasic disease other than MS (7%). At least one form of residual deficit including cognitive impairment was observed in 69% of all ADS patients, even in monophasic ADS. An Expanded Disability Status Scale score of ≥ 5.5 was reached in 3/89 MS patients (3%).

CONCLUSION

The reported incidence of ADS in Dutch children has increased since 2010. Residual deficits are common in this group, even in monophasic patients. Therefore, long-term follow-up in ADS patients is warranted.

Multi-component relaxation in clinically isolated syndrome: Lesion myelination may predict multiple sclerosis conversion

We performed a longitudinal case-control study on patients with clinically isolated syndrome (CIS) with the aid of quantitative whole-brain myelin imaging. The aim was (1) to parse early myelin decay and to break down its distribution pattern, and (2) to identify an imaging biomarker of the conversion into clinically definite Multiple Sclerosis (MS) based on in vivo measurable changes of myelination.

Imaging and clinical data were collected immediately after the onset of first neurological symptoms and follow-up explorations were performed after 3, 6, and, 12 months. The multi-component Driven Equilibrium Single Pulse Observation of T1/T2 (mcDESPOT) was applied to obtain the volume fraction of myelin water (MWF) in different white matter (WM) regions at every time-point. This measure was subjected to further voxel-based analysis with the aid of a comparison of the normal distribution of myelination measures with an age and sex matched healthy control group. Both global and focal relative myelination content measures were retrieved.

We found that (1) CIS patients at the first clinical episode suggestive of MS can be discriminated from healthy control WM conditions (p < 0.001) and therewith reproduced our earlier findings in late CIS, (2) that deficient myelination in the CIS group increased in T2 lesion depending on the presence of gadolinium enhancement (p < 0.05), and (3) that independently the CIS T2 lesion relative myelin content provided a risk estimate of the conversion to clinically definite MS (Odds Ratio 2.52).

We initially hypothesized that normal appearing WM myelin loss may determine the severity of early disease and the subsequent risk of clinically definite MS development. However, in contrast we found that WM lesion myelin loss was pivotal for MS conversion. Regional myelination measures may thus play an important role in future clinical risk stratification.

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The multicomponent relaxation method mcDESPOT allowed 3D resolved data acquisition appropriate for group comparison and voxel-wise analysis.

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Myelin imaging in early clinically isolated syndrome revealed initial imaging widespread myelin loss even in normal appearing brain tissue.

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In clinically isolated syndrome the myelin measures varied depending on the presence of Gadolinium enhancement.

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Short-term risk of clinically isolated syndrome to convert to multiple sclerosis was determined by myelin measures within white matter lesions.