Treatment of multiple sclerosis and neuromyelitis optica in children and adolescents

Prognostic indicators of improvement with therapeutic plasma exchange in pediatric demyelination

OBJECTIVES

To determine the safety and clinical benefit of therapeutic plasma exchange (TPE) as rescue therapy in children with acute inflammatory demyelinating CNS syndromes and to identify baseline prognostic indicators of treatment improvement.

METHODS

This single-center retrospective pediatric cohort included all consecutive patients admitted to our hospital over the period from 2003 to 2017 because of a steroid-refractory acute CNS event presumed to be inflammatory who required TPE. Functional status assessment to identify improvement included the following performance category scales: visual outcome, bladder control, gait, and Expanded Disability Status Scale (EDSS). These assessments were performed before and after TPE in every patient.

RESULTS

Sixty-five children requiring TPE to treat 78 CNS attacks were included for analysis. Median age at TPE was 10.5 years (1.9-18 years); 45% were girls. Seropositivity (aquaporin-4 water channel-immunoglobulin G [IgG] or myelin oligodendrocyte glycoprotein-IgG) was found in 20 of 42 (48%) patients. Attack phenotypes leading to TPE were optic neuritis (ON) in 42%, longitudinally extensive transverse myelitis (LETM) in 31%, ON + LETM in 15%, and other combined syndromes in 11%. Overall, moderate to marked neurologic improvement was observed in 72% of children at the end of TPE and in 88.5% at 6 months of follow-up. Lower baseline scores on the EDSS, visual outcome, and gait scales were found to be independent prognostic indicators of treatment benefit. Sex, age at onset and at TPE, attack phenotype, disease duration, and time from attack onset to TPE initiation were not significantly associated with treatment outcome. Adverse events were observed in 31 of 524 (5.9%) procedures, being severe in 4.

CONCLUSIONS

TPE was an effective rescue therapy associated with functional improvement. No therapeutic window for TPE initiation was identified in this pediatric cohort. Overall frequency of adverse events was low; however, serious events should be anticipated and avoided.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that for children with acute inflammatory demyelinating CNS syndromes, TPE leads to functional improvement.

Neuromyelitis optica spectrum disorder in pediatrics. Case report

Introduction: Neuromyelitis optica is an inflammatory disorder of the central nervous system that accounts for 5% of demyelinating diseases in pediatrics. Its clinical presentation is variable and associated to the involved area of the central nervous system.Case presentation: This is the case of a 15-year-old patient who consulted several times for nonspecific neurological symptoms. During his last visit to the Clínica Universitaria Colombia in Bogotá, he presented with bilateral optic neuritis, associated with frontal and parietal headache. Immunophenotyping studies were carried out, reporting positive IgG anti-aquaporin 4 antibodies (anti-AQP4 antibody), thus leading to a diagnosis of seropositive neuromyelitis optica spectrum disorder (NMOSD). Management with methylprednisolone pulses was initiated with subsequent outpatient management with rituximab that allowed stabilizing the disease.Discussion: This is an interesting case due to its insidious and uncertain onset in a pediatric patient. It was possible to evaluate clinical and diagnostic differences in relation to its presentation in adults. NMOSD mediated by anti-AQP4 is rare; brain and bone marrow MRI are essential for diagnosis. The treatment of choice for acute conditions consists of high doses of methylprednisolone.Conclusion: This disorder may result in irreversible neurological damage; for this reason, high suspicion is required for early diagnosis and timely treatment.

Therapeutic plasma exchange in paediatric neurology: a critical review and proposed treatment algorithm

Therapeutic plasma exchange (TPE) has been a key immunotherapeutic strategy in numerous neurological syndromes, predominantly during the acute phase of illness. This paper reviews the indications, strength of evidence, and safety of TPE in children with neurological conditions. The rarity of these immune conditions in children, alongside an often incomplete understanding of their pathobiology, has limited the development of a robust scientific rationale for TPE therapy and the feasibility of conducting larger controlled trials. TPE continues to be used, but is a costly therapy with common adverse effects. Uncertainty remains over how to compare the different TPE methods, the optimal dosage of therapy, and monitoring and integration of TPE with other immunotherapies. Further studies are also required to define the indications and benefits of TPE and assess evolving technologies such as immunoadsorption.

WHAT THIS PAPER ADDS

Studies investigating therapeutic plasma exchange (TPE) are small and mainly uncontrolled. They provide evidence for the efficacy of TPE in childhood neuro-inflammatory conditions. TPE is generally well tolerated provided key adverse effects are anticipated and avoided. Systematic dosing and objective assessment of treatment effect should be priorities for future research.

Cerebral Blood Flow Changes in Multiple Sclerosis and Neuromyelitis Optica and Their Correlations With Clinical Disability

Distinguishing relapsing-remitting multiple sclerosis (RRMS) and neuromyelitis optica (NMO) is clinically important because they differ in prognosis and treatment. This study aimed to identify perfusion abnormalities in RRMS and NMO and their correlations with gray matter volume (GMV) atrophy and clinical parameters. Structural and arterial spin labeling MRI scans were performed in 39 RRMS patients, 62 NMO patients, and 73 healthy controls. The gray matter cerebral blood flow (CBF) values were voxel-wisely compared among the three groups with and without GMV correction. The regional CBF changes were correlated with the Expanded Disability Status Scale scores in the corresponding patient groups. Although multiple brain regions showed CBF differences among the three groups without GMV correction, only three of these regions remained significant after GMV correction. Specifically, both the RRMS and NMO groups showed reduced CBF in the occipital cortex and increased CBF in the right putamen compared to the control group. The RRMS group had increased CBF only in the medial prefrontal cortex compared to the other two groups. The occipital CBF was negatively correlated with clinical disability in the NMO group; however, the CBF in the right putamen was positively correlated with clinical disability in both patient groups. These findings suggest that there are perfusion alterations independent of GMV atrophy in RRMS and NMO patients. The regional CBF in the occipital cortex and putamen could be used as imaging features to objectively assess clinical disability in these patients.

The Use of Natalizumab in Pediatric Patients With Active Relapsing Multiple Sclerosis: A Prospective Study

BACKGROUND

Pediatric multiple sclerosis (MS) has been increasingly recognized. In the absence of approved disease-modifying therapies (DMTs) for pediatric patients, clinicians resort to data extrapolated from clinical trials conducted in adults with MS. The objective of this article was to study the effectiveness and safety of natalizumab in with pediatric MS.

METHODS

Patients with pediatric MS (aged less than 18 years) who had been treated with natalizumab were followed up prospectively as part of the national MS registry. Data of relapsing patients who had at least a one-year follow-up were analyzed. The primary outcome measure was the annual relapse rate after natalizumab treatment. Secondary outcomes measures included the mean change in disease progression measured by the expanded disability status scale and the proportion of patients with radiologic activity (gadolinium-enhancing or new T2 lesions) at the last follow-up visit.

RESULTS

Thirty-two patients with pediatric MS had been treated with natalizumab for at least 12 months, of whom 72% were females. The mean age at onset and disease duration were 14.9 ± 2.6 and 5.1 ± 3.1 years, respectively. Most patients (n = 21, 66%) had breakthrough disease on first-line disease-modifying therapies. The mean number of natalizumab infusions was 34.5 ± 18. The annual relapse rate was significantly reduced (1.66 ± 0.5 vs 0.06 ± 0.25; P < 0.001), whereas the mean expanded disability status score improved (3.3 ± 1.3 vs 2.2 ± 1.0; P < 0.001) at the last follow-up visits. The proportion of patients with magnetic resonance imaging activity was significantly reduced (93.8% versus 12.5%; P < 0.001). No major adverse events were observed.

CONCLUSION

In our pediatric MS cohort with aggressive or breakthrough disease, treatment with natalizumab was effective in reducing clinical and radiologic disease activity. Natalizumab has a similar clinical efficacy and safety profile as in adult MS.

Multiple sclerosis in the very young: a case report and review of the literature

Onset of multiple sclerosis (MS) in the very young (<10 years) is uncommon. We describe a 2 year old girl with MS, the youngest reported case in the USA. She presented to an outside hospital with acute onset of ataxia on three occasions before presenting to our institution, initially misdiagnosed as acute disseminated encephalomyelitis and treated with intravenous methylprednisolone. MRI of the brain during each presentation revealed new areas of demyelination. Initial cerebrospinal fluid (CSF) studies and MRI of the spine were normal. Repeat MRI of the brain at our institution, 7 months later, revealed new demyelinating lesions and CSF analysis revealed elevated myelin basic protein, negative oligoclonal band and neuromyelitis optica immunoglobulin and normal IgG synthesis. Her clinical presentation with multiple relapses and new MRI findings validated the diagnosis of MS.

Fingolimod Prescribed for the Treatment of Multiple Sclerosis in Patients Younger Than Age 18 Years

BACKGROUND

There have been no clinical trials for approval of medications for treating multiple sclerosis in patients younger than age 18 years. All treatments are based on personal experience and data from open observational studies. Fingolimod is an oral drug for multiple sclerosis that has been shown to be efficient and safe in adults. The aim of our study is to describe patients with multiple sclerosis who started treatment with fingolimod before the age of 18 years.

PARTICIPANTS AND METHODS

Seventeen patients treated with fingolimod were identified in the Brazilian database of children and adolescents with multiple sclerosis. The average time of use of the drug was 8.6 months.

RESULTS

Fingolimod showed a good safety and efficacy profile in these patients, all of whom had very active multiple sclerosis. After starting treatment with fingolimod, only one patient had a relapse and a new lesion on magnetic resonance imaging. The patients' degree of disability did not progress. No major adverse events were reported in relation to the first dose of the drug, nor in the short- and medium-term treatment. No patient has been followed for longer than 18 months, thus limiting long-term conclusions.

CONCLUSIONS

Off-label use of fingolimod in patients younger than age 18 years may be a good therapeutic option for multiple sclerosis control.