Neuromyelitis Optica

Cognitive and psychopathological features of neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease: A narrative review

Clinicians are becoming increasingly aware of the cognitive and psychopathological consequences of neurological diseases, which were once thought to manifest with motor and sensory impairments only. The cognitive profile of multiple sclerosis, in particular, is now well-characterised. Similar efforts are being made to better characterise the cognitive profile of other central nervous system inflammatory demyelinating autoimmune disorders. This review discusses the current understanding of the cognitive and psychological features of neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). Detailed analysis of the cognitive sequelae of the above conditions can not only assist with understanding disease pathogenesis but also can guide appropriate management of the symptoms and consequently, improve the quality of life and long-term outcomes for these patients. This narrative review will also identify research gaps and provide recommendations for future directions in the field.

Nationwide analysis of neuromyelitis optica in systemic lupus erythematosus and Sjogren's syndrome

OBJECTIVE

Neuromyelitis optica (NMO), also known as Devic's disease, is a rare inflammatory demyelinating disorder causing myelitis and optic neuritis. While there have been reports of systemic lupus erythematosus (SLE) and primary Sjogren's syndrome (SS) occurring with NMO, a formal association is not established. We aimed to investigate the occurrence of NMO in SLE and SS patients and study the clinical characteristics and outcomes of NMO and SLE/SS hospitalizations utilizing the national inpatient sample (NIS) database.

METHODS

The NIS database from 2016 to 2019 was used to extract data. Adult hospitalizations with the principal or secondary diagnosis of NMO were included. We classified NMO patients with and without concomitant diagnosis of SLE or Sjogren's syndrome. We evaluated and compared the clinical characteristics and outcomes of NMO hospitalizations with and without SLE or Sjogren's syndrome. STATA17 was used for data analysis. We also calculated the odds ratio of NMO in SLE and Sjogren's syndrome.

RESULTS

There were a total of 16,360 adult hospitalizations with the principal or secondary discharge diagnosis of NMO. Among all NMO hospitalizations, 1425 (8.71%) had the primary or secondary diagnosis of SLE or SS. The odds of NMO in SLE and Sjogren's syndrome were noted to be 12.29 and 5.56, respectively. NMO with SLE/SS group had higher proportion of females (89.82% vs 79%, P value < 0.001), African Americans (56.63% vs 38.28, P value < 0.001), and Asians (5.73% vs 3.25, P value 0.04). The Charlson comorbidity index was higher for NMO-SLE/SS overlap (2.44 vs 1.28, P value < 0.001). There was no significant difference in overall mortality rates of both groups (2.11% vs 1.2%, P value 0.197). There were significantly higher reported seizures (14.73% vs 6.05, P value < 0.001) and paraplegia (21.75% vs 13.93%, P value < 0.001) in NMO-SLE/SS patients. These patients also had a longer length of stay in comparison to the reference group (7 vs 5 days, P value < 0.001) as well as higher total charges.

CONCLUSIONS

NMO patients had a 12-fold higher risk of SLE and 5-fold higher risk of Sjogren's disease when compared to general population. Patients with overlap of NMO and SLE or Sjogren's were predominantly women and were more likely to be African-American. Co-existence of these autoimmune disorders was associated with poor prognosis in terms of higher morbidity for patients and increased health care burden. Key Points • NMO is a rare autoimmune disease seen predominantly in women in the middle age group with low overall mortality. • SLE and Sjogren's have increased odds of NMO in comparison to general population. • NMO patients have high rates of several complications such as paraplegia, quadriplegia, seizures, blindness, sepsis, and respiratory failure with even higher rates of seizures and paraplegia in those with concomitant SLE or Sjogren's.

Percutaneous cervical cordotomy for chest wall pain from mesothelioma in the setting of neuromyelitis

A 75-year-old man presented to our Interventional Cancer Pain service for consideration of a percutaneous cervical cordotomy (PCC) to control severe chest wall pain secondary to malignant mesothelioma. His medical history included a neuroinflammatory disorder, neuromyelitis optica, for which he had previously had a prolonged hospital admission, with ongoing neurological deficit. Little information is available regarding the safety of PCC in a patient with this condition, specifically the risk of neurological relapse, and we were initially wary about going ahead. After discussion with the patient's neurology team and other UK experts and with the patient's informed consent, we proceeded to PCC with additional steroid cover. No adverse neurological symptoms were encountered perioperatively or postoperatively and the patient had an excellent analgesic result. As this combination of circumstances has not to our knowledge been documented, we wished to present this case and discuss the factors affecting our decision and management.

Inebilizumab for neuromyelitis optica spectrum disorders in Italy: a budget impact model

BACKGROUND

The Italian National Health Service (INHS) has recently reimbursed the monoclonal antibody inebilizumab as a second line monotherapy after rituximab (RTX) use for neuromyelitis optica spectrum disorders (NMOSD) patients ≥ 18 years anti-aquaporin 4 antibody-immunoglobulin G positive, who experienced a relapse in the last year or cannot receive RTX, if incident patients. Other INHS-reimbursed drugs for NMOSD treatment are satralizumab, eculizumab and, off-label, besides RTX, ocrelizumab, tocilizumab, and immunosuppressants.

RESEARCH DESIGN AND METHODS

A 3-year (2023-2025) prevalence-based budget impact model following the INHS viewpoint compared the costs and the NMOSD attacks without (1st scenario) and with inebilizumab (2nd scenario). The epidemiology of NMOSD, and the INHS-funded healthcare resources (drugs and their administration; specialist visits; hospitalizations due to drug-related adverse events and NMOSD attacks) were obtained from the literature. One-way, threshold value and scenario sensitivity analyses investigated the robustness of the baseline findings.

RESULTS

During 2023-2025 inebilizumab saves the INHS €8,373,125.13 (1st scenario: €176,770,028.63; 2nd scenario: €168,396,903.50) and 12.74 NMOSD attacks (1st scenario: 213.94; 2nd scenario: 201.19). Sensitivity analyses confirmed the robustness of the baseline results.

CONCLUSION

Inebilizumab reduces the INHS expenditure for NMOSD drugs. Future research should explore the cost-effectiveness of inebilizumab vs other NMOSD-targeting drugs in Italy.

Compressive Optic Neuropathy Caused by Internal Carotid Artery Aneurysm Presenting with Concurrent Neuromyelitis Optica

Purpose: To report a case of compressive optic neuropathy caused by an internal carotid artery aneurysm accompanied by concurrent neuromyelitis optica (NMO).Case summary: A 48-year-old female presented with sudden painless blurry vision in the inferior visual field of her right eye for 2 days. The corrected visual acuity was 0.7 in the right eye, and a relative afferent pupillary defect was observed. The visual field test demonstrated an inferior altitudinal defect in the right eye, while the color vision test was normal. However, after 5 days, she developed decreased color vision. Optic nerve enhancement in the right eye was observed on orbital magnetic resonance imaging, and anti-aquaporin-4 antibody was positive. She was diagnosed with NMO, and high-dose steroids were administered intravenously. In addition, brain magnetic resonance angiography showed a 5-mm aneurysm in the ophthalmic segment of the right internal carotid artery, which was compressing the optic nerve. Coil embolization of the aneurysm was performed. On the fourth day of steroid therapy and the first day after coiling, the corrected visual acuity in the right eye improved to 1.0. At 6-week follow-up, color vision and visual field defect also showed complete recovery.Conclusions: In this rare case of internal carotid artery aneurysm combined with NMO, early active treatment led to complete recovery of visual acuity and field defects.

A Rare Case of Neuromyelitis Optica Spectrum Disorders With Unknown Fever and Subacute Cognitive Decline With Normal Images

We report the case of a 69-year-old Japanese man who came to our hospital with a chief complaint of fever and cognitive decline for three weeks. There were no neurological abnormalities other than the decreased level of consciousness. He developed urinary retention after admission, so we performed a lumbar puncture, although his head and neck magnetic resonance imaging (MRI) showed no abnormal findings. The cerebrospinal fluid (CSF) examination showed albuminocytologic dissociation and the anti-aquaporin 4 antibody was positive. Thus, we diagnosed him with neuromyelitis optica spectrum disorder (NMOSD). NMOSD is an autoimmune disease that causes demyelination. The clue to diagnosing NMOSD is demyelinating findings on MRI. Therefore, it is difficult to diagnose NMOSD if there are no abnormalities on the images. However, abnormal MRI findings are not necessary for the diagnosis of NMOSD. Thus, NMOSD cannot be ruled out even if MRI findings are normal and the real clue to diagnosing NMOSD is the anti-aquaporin 4 antibody.

Vaccination in neuromyelitis optica spectrum disorders: Friend or enemy?

Neuromyelitis optica spectrum disorders (NMOSDs) are uncommon antibody-mediated autoimmune diseases of the central nervous system (CNS), mainly occurring in optic nerves and spinal cord, which can cause visual impairment, paralysis, and occasionally bulbar dysfunction. Such neurological deficits can adversely affect pulmonary functions and increase complicated infection risk. Besides, most NMOSD patients undergo immunosuppressive therapy. All these factors make NMOSD patients the potential high-risk group under the current pandemic of coronavirus disease 2019 (COVID-19). Meanwhile, COVID-19 infection has already been demonstrated as a risk factor for NMOSD relapses. This review discusses the basic immunology of vaccination and common problems, including immunogenicity, safety, and efficacy of vaccination on NMOSD patients. Additionally, we offered vaccination recommendations, health care and treatment advice for NMOSD patients under the background of COVID-19.

Immunosuppression in Multiple Sclerosis and Other Neurologic Disorders

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) characterized by peripheral immune cell infiltration into the brain and spinal cord, demyelination, glial cell activation, and neuronal damage. Currently there is no cure for MS, however, available disease-modifying agents minimize inflammation in the CNS by various mechanisms. Approved drugs lessen severity of the disease and delay disease progression, however, they are still suboptimal as patients experience adverse effects and varying efficacies. Additionally, there is only one disease-modifying therapy available for the more debilitating, progressive form of MS. This chapter focuses on the presently-available therapeutics and, importantly, the future directions of MS therapy based on preclinical studies and early clinical trials. Immunosuppression in other neurological disorders including neuromyelitis optica spectrum disorders, myasthenia gravis, and Guillain-Barré syndrome is also discussed.

Patients with neuromyelitis optica spectrum disorder (NMOSD) are associated with adverse outcome after total hip arthroplasty: a matched case-control study

Background

Neuromyelitis Optica Spectrum Disorders (NMOSD) are rare inflammatory diseases of the central nervous system that cause transverse myelitis and optic neuritis. Steroids are commonly administered in NMOSD patients. The use of steroids may lead to osteonecrosis, which makes some of the NMOSD patients candidate for total hip arthroplasty (THA). To date, the clinical outcome of THA in NMOSD patients have not been investigated.

Aim

Investigate the patient reported outcome measures (PROM), radiographic outcome and complication in NMOSD patients after THA, compared with that of non-NMOSD patients.

Methods

Patients from Jan. 2016 to October. 2020 were identified in our database. 12 NMOSD cases which met the inclusion criteria were matched to non-NMOSD cases in a ratio of 1:2 based on age, sex, Charlson Comorbidity Index (CCI) and surgical date. Relevant outcome were analyzed and compared between the two groups.

Results

There was a significantly increased risk of dislocation in NMOSD patients. Post-operative HOOS score was similar between the two groups even though the pre-operative HOOS score is significantly higher in the non-NMOSD group. NMOSD patients had poor performance in EQ-5D and EQ-VAS. The cups were placed more anteverted in NMOSD cases (P = 0.01).

Conclusion

There is a significantly increased risk of dislocation after THA in NMOSD patients. However, satisfactory improvement in functional outcome of the hip was achieved. Due to the natural process of NMOSD, rehabilitation and hip precaution should be patient-specific and time-specific.

Prognostic factors in Tumefactive demyelinating lesions: A retrospective study

INTRODUCTION

Demyelinating lesions occasionally present as mass-like lesions on imaging, raising concern for malignancy. The disease course of such tumefactive demyelinating lesions (TDLs) is still being defined.

METHODS

We retrospectively analyzed 21 patients with new-onset neurologic symptoms and mass-like lesions on brain magnetic resonance imaging (MRI), which resulted in biopsy-proven diagnoses of demyelination. 18 patients had a median follow-up of 52 months. The clinical, radiologic and histologic features were associated with disease course.

RESULTS

An aggressive disease course (ADC) was noted in 33% of the patients and was associated with an initial largest lesion size ≥35 mm (p = 0.0007), mass effect (p = 0.01) and perilesional edema (p = 0.01) on MRI. Age 30 years and older, at presentation (p = 0.05), as well as the absence of a prior tonsillectomy (p = 0.0128) were also associated with an ADC.

CONCLUSIONS

We identified several factors, including initial larger lesion size, mass effect and perilesional edema on MRI, presentation after 30 years of age and the absence of a prior tonsillectomy, that predict an ADC in patients presenting with TDLs. These predictors of disease course can help guide patient follow-up and stratification for intervention.

Fatal Enterovirus-related Myocarditis in a Patient with Devic's Syndrome Treated with Rituximab

Enteroviruses are a frequent source of infection and among the most common central nervous system viral pathogens. Enteroviruses – in particular, the Coxsackie B viruses – are a known cause of myocarditis. Rituximab is a genetically engineered chimeric anti-CD20 monoclonal antibody. Many reports in the literature suggest a higher risk of infection following repeated rituximab therapy, including viral infection. However, observations of enterovirus-related myocarditis in the context of rituximab treatment are scarce. The authors describe the case of a patient with neuromyelitis optica spectrum disorder who developed severe and fatal enterovirus-related myocarditis after rituximab therapy with a difficult differential diagnosis of autoimmune or giant-cell myocarditis. This case highlights the importance of complete diagnostic workup in difficult cases of myocarditis, including endomyocardial biopsies.

Epidemiology of Demyelinating Diseases in Korean Pediatric Patients

The epidemiology of demyelinating diseases in the Korean pediatric population has not been reported to date. This study aimed to identify the epidemiology of demyelinating diseases in Korean children by using big data. The subjects were children (0-17 years old) diagnosed with acute-disseminated encephalomyelitis, multiple sclerosis, neuromyelitis optica, and Guillain-Barré syndrome enrolled in the Korean Health Insurance Review and Assessment Service (HIRA) from January 2010 to December 2017.Of 1722 enrolled children, 553 (32.1%) had acute-disseminated encephalomyelitis, 170 (9.9%) had multiple sclerosis, 68 (3.9%) had neuromyelitis optica, and 931 (54.1%) had Guillain-Barré syndrome. The male-female ratios were 1.47:1 in acute-disseminated encephalomyelitis, 1.43:1 in Guillain-Barré syndrome, 1:1.66 in multiple sclerosis, and 1:1.62 in neuromyelitis optica. Demyelinating diseases were most prevalent in summer. The prevalence differed by region, with 545 (31.6%) in Seoul and 298 (17.3%) in Gyeonggi. This study is the first to identify the incidence of demyelinating diseases in South Korea.

Pathophysiologic role of Interleukin-33/ST2 in Sjögren's syndrome

Interleukin-33 (IL-33) is a member of the IL-1 family and has dual functions as a nuclear factor as well as a cytokine. The pivotal role of IL-33 as an active player contributing to aberrant local and systemic damage has been highlighted in several inflammatory and autoimmune diseases. Primary Sjögren's syndrome (pSS) is an autoimmune disease characterized by dry eyes and mouth syndrome due to local dysfunctions of exocrine glands, but also accompanied with systemic manifestations. The pathophysiology of pSS has been advocated as a conjecture of activated B and T cells as well as the production of inflammatory cytokines and autoantibodies, driving epithelial tissue damage and disease progression. In pSS, IL-33 is released in the extracellular space from damaged salivary cells upon pro-inflammatory stimuli and/or dysfunction of epithelial barrier. Counter-regulatory mechanisms are initiated to limit the pro-inflammatory actions of IL-33 as portrayed by an increase in the decoy receptor for IL-33, the soluble form of ST2 (sST2). In pSS and associated diseases, the levels of IL-33 are significantly elevated in the serum or tears of patients. Mechanistically, IL-33 acts in synergy with IL-12 and IL-23 on NK and NKT cells to boost the production of IFN-γ contributing to inflammation. TNF-α, IL-1β and IFN-γ in turn further increase the activation of IL-33/ST2 pathway, thereby constituting a vicious inflammatory loop leading to disease exacerbation. IL-33/ST2 axis is involved in Sjögren's syndrome and opens new perspectives as therapeutic target of one of the culprits in the inflammatory perpetuation.

Clinical and Radiological Characteristics of Neuromyelitis Optica Spectrum Disorder: The Experience from Saudi Arabia

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune astrocytopathy that affects several regions of the central nervous system (CNS) with a predilection for the optic nerves and spinal cord. Epidemiological studies of NMOSD are uncommon in the Middle East and up-to-date, there are no such data from Saudi Arabia. In this study, we aim to study the clinical pattern of NMOSD patients in Saudi Arabia.

METHODS

A retrospective multi-center observational study was conducted at King Abdulaziz Medical City in Jeddah and Riyadh, Saudi Arabia. The inclusion criteria consisted of all the patients with either neuromyelitis optica according to the 2006 criteria or NMOSD according to the 2015 criteria. The study period was 20 years.

RESULTS

A total of 23 patients were included in the study. Four were males (17.4%) and 19 were females (82.6%). The attack type was optic neuritis in 3 patients (13.0%), transverse myelitis in 15 patients (65.2%), and both in 5 patients (21.7%). All patients (100%) received pulse steroid therapy (intravenous methylprednisolone 1 g for 5 days) at the onset of the disease. Fifteen patients had plasma exchange therapy (65.2%). All patients received maintenance immunosuppressive treatment except 1 (4.3%).

CONCLUSION

NMOSD is a rare, broad-spectrum, polyphasic, rare disorder primarily affecting the optic pathway and the spinal cord either in isolation or simultaneously. Unfortunately, there are no adequate studies that assess NMOSD cohorts in Saudi Arabia despite the increased number of diagnosed cases. In addition, there is no registry for this disorder with only a few specialized centers dealing with its management. It is time to establish specialized demyelinating disease centers and build expertise in both common and rare diseases in this category.

Electrical muscle stimulation intervention in the acute phase of neuromyelitis optica: Two case reports

The aim of this study was to examine the effect of electrical muscle stimulation on muscle atrophy caused by neuromyelitis optica. Two neuromyelitis optica patients with flaccid paralysis participated. The participants underwent a general rehabilitation program (transfer, balance, and gait training) and electrical muscle stimulation on the quadriceps femoris muscle of their paralyzed side. The change in the thickness of the vastus lateralis muscle ranged from -0.6 to 1.4 mm. These changes were minimal and did not indicate muscle atrophy. These findings suggest that in addition to general physiotherapy, electrical muscle stimulation seems safe and feasible in the acute phase of neuromyelitis optica.

Cognitive impairment in NMOSD-More questions than answers

INTRODUCTION

Neuromyelitis optica spectrum disorder (NMOSD) is a type of central nervous system antibody-mediated disease which affects mainly optic nerves and spinal cord, but may also present with acute brainstem syndrome, acute diencephalic syndrome, and cerebral syndrome with typical brain lesions. One of the most disabling symptoms, diagnosed in 29%-67% of cases, is cognitive dysfunction, with such processes as memory, processing speed, executive function, attention, and verbal fluency being predominantly affected. However, description of cognition in NMOSD patients is still a relatively new area of research.

METHODS

A systematic MEDLINE search was performed to retrieve all studies that investigated cognitive impairment and its clinical correlates in patients with NMOSD.

RESULTS

We summarize the current knowledge on cognitive impairment profile, neuropsychological tests used to examine NMOSD patients, clinical and demographical variables affecting cognition, and magnetic resonance imaging correlates. We provide a comparison of cognitive profile of patients with multiple sclerosis and NMOSD.

CONCLUSION

Patients with NMOSD are at significant risk of cognitive deficits. However, the knowledge of cognitive symptoms in NMOSD and potential modifying interventions is still scarce. Further accumulation of clinical data may facilitate effective therapeutic interventions.

Associations between IL1RAP rs4624606, IL1RL1 rs1041973, IL-6 rs1800795, and HTRA1 rs11200638 gene polymorphisms and development of optic neuritis with or without multiple sclerosis

BACKGROUND

Optic neuritis (ON) and multiple sclerosis (MS) are complex diseases with multifactorial pathogenesis. The role of genetic factors in the development of these diseases is hypothesized, and specific biochemical components involved in the pathogenesis of ON and MS are yet to be determined. The aim of our study was to determine the associations between IL1RAP rs4624606, IL1RL1 rs1041973, IL-6 rs1800795, and HTRA1 rs11200638 gene polymorphisms and development of ON with or without MS.

MATERIALS AND METHODS

The study subjects included 80 ON patients and 146 healthy controls (HCs). Genotyping of IL1RAP rs4624606, IL1RL1 rs1041973, IL-6 rs1800795, and HTRA1 rs11200638 was performed using real-time polymerase chain reaction.

RESULTS

A/C genotype of IL1RL1 rs1041973 was more frequent in ON patients than in HC subjects (p = 0.026). The IL1RL1 rs1041973 A/C genotype was associated with increased odds of ON development under the overdominant (p = 0.041) model.

CONCLUSIONS

Our study showed that IL1RAP rs4624606, IL-6 rs1800795, and HTRA1 rs11200638 are not associated with an increased risk of developing ON. However, the IL1RL1 rs1041973 A/C genotype might be associated with an increased risk of developing ON.

Serum immunoglobulin a deficiency and autoimmune comorbidities: a crossectional study in 281 patients with systemic lupus erythematosus

OBJECTIVE To study the profile of associated autoimmune diseases in a series of patients with systemic lupus erythematosus (SLE) and see if such associations are linked to IgA deficiency. METHODS Two hundred eighty-one patients with SLE were studied for Ig A levels by nephelometry. Levels equal to or under 0.05g/dL were considered as IgA deficiency. Epidemiological and clinical data, including the presence of associated autoimmune diseases, were extracted from the patient's charts. RESULTS Ig A deficiency was found in 6% of the patients. In 30.2% of SLE patients, there was at least one more autoimmune disease; Hashimoto thyroiditis and Sjögren's syndrome were the most common. No association between the occurrence of associated autoimmune disease with IgA deficiency was found. CONCLUSIONS There is a high prevalence of autoimmune diseases associated with SLE. IgA deficiency does not affect the presence of these associations.

Magnetic resonance imaging of intraocular optic nerve disorders: review article

The optic nerve is morphologically classified as a peripheral nerve, but histologically it shares characteristics with the central nerves. Diseases that affect vision and the optic nerve are many and varied: optic neuritis, demyelination (multiple sclerosis, acute disseminated encephalomyelitis, neuromyelitis optica spectrum disorder, and myelin oligodendrocyte glycoprotein antibody-related disorders), drugs, collagen disease, vasculitis, infection, trauma, vascular abnormalities, tumours, and non-tumoural masses. In this review, we summarise the magnetic resonance imaging findings for various pathological conditions that cause deterioration in visual acuity.

The Potential Immunoregulatory Roles of Vitamin D in Neuromyelitis Optica Spectrum Disorder

Neuromyelitis optica spectrum disorder (NMOSD) is an autoantibody-mediated disease affecting the central nervous system (CNS). Its pathogenesis involves both innate and acquired immune reactions; specific antibody (Aquaporin-4 antibody) and inflammatory cells cause direct damage on lesion sites, while B cell-T cell interactions facilitate the demyelination. However, its etiology is still not fully understood. Vitamin D deficiency is present in numerous autoimmune diseases, including NMOSD. Evidence suggests that low vitamin D levels mayassociate with disease activity and relapse rate in NMOSD, indicating the participation in the pathogenesis of NMOSD. The immunoregulatory roles of vitamin D in both numerous autoimmune diseases and experimental autoimmune encephalomyelitis (EAE) models are increasingly recognized. Recent studies have revealed vitamin D modulation in cytokine production, immune cell development and differentiation, as well as antibody production. By enhancing an anti-inflammatory environment and suppressing the overactivated autoimmune process, vitamin D shows its potential immunoregulatory roles in NMOSD, which could possibly introduce a new therapy for NMOSD patients.

Experimental Models of Neuroimmunological Disorders: A Review

Immune-mediated inflammatory diseases of the central nervous system (CNS) are a group of neurological disorders in which inflammation and/or demyelination are induced by cellular and humoral immune responses specific to CNS antigens. They include diseases such as multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD), acute disseminated encephalomyelitis (ADEM) and anti-NMDA receptor encephalitis (NMDAR encephalitis). Over the years, many in vivo and in vitro models were used to study clinical, pathological, physiological and immunological features of these neuroimmunological disorders. Nevertheless, there are important aspects of human diseases that are not fully reproduced in the experimental models due to their technical limitations. In this review, we describe the preclinical models of neuroimmune disorders, and how they contributed to the understanding of these disorders and explore potential treatments. We also describe the purpose and limitation of each one, as well as the recent advances in this field.

Use of ganglion cell layer analysis for diagnosing anti-glycoprotein neuromyelitis optica of oligodendrocyte myelin

The case concerns a 26-year-old patient with bilateral recurrent optic neuritis episodes in the context of suspected neuromyelitis optica. In the first outbreak, she had greatly impaired visual acuity of the left eye, as well as seeing ganglion cell layer damage in both eyes in the optic coherence tomography, with evidence of a possible extensive lesion in the optic chiasma. Likewise, MRI with contrast showed a great involvement of the left optic nerve that compromises the chiasma increasing the suspicion of a neuromyelitis origin. Althogh the anti-myelin oligodendrocyte glycoprotein (MOG) and anti-AQP4 (aquaporin-4) antibodies were negative at first, bilateral involvement of the ganglion cells suggested an extensive lesion that is more characteristic of seropositive anti-MOG neuromyelitis.

Ocular manifestations in celiac disease: an overview

PURPOSE

To review and highlight the ocular manifestations associated with celiac disease (CD) and presentation of their pathogenetic mechanisms.

METHODS

A thorough review of the literature was performed using PubMed to identify articles about serrated polyposis syndrome. The search was performed using the search string: ("celiac disease" OR "coeliac disease") AND ("ocular manifestations" OR "eye" OR "orbitopathy" OR "uveitis" OR "neuro-ophthalmic manifestations"). Only articles in English were reviewed.

RESULTS

Several ocular symptoms and disorders have been associated with CD and are a result of defective intestinal absorption and immunological mechanisms. These include nyctalopia, dry eye, cataract, thyroid-associated orbitopathy, uveitis, central retinal vein occlusion and neuro-ophthalmic manifestations. In addition, CD-related ocular disease may represent the first manifestation of CD.

CONCLUSION

CD may hold accountable for the development of ocular diseases of obscure etiology.

Abnormal Baseline Brain Activity in Neuromyelitis Optica Patients Without Brain Lesion Detected by Resting-State Functional Magnetic Resonance Imaging

OBJECTIVE

To investigate the baseline brain activity in neuromyelitis optica patients without brain lesion using the regional amplitude of low-frequency fluctuation (ALFF) and fractional amplitude of low-frequency fluctuation (fALFF) as indexes.

MATERIALS AND METHODS

Forty-two patients of NMO with normal performance in conventional MRI and 42 healthy controls, matched in gender and age, were enrolled in this study. Resting-state functional magnetic resonance imaging (rs-fMRI) data acquired using the rs-fMRI Data Analysis Toolkit. The relationships between expanded disability states scale (EDSS) scores, abnormal baseline brain activity and disease duration were explored.

RESULTS

The left inferior temporal, left cerebellum_4_5, bilateral superior temporal pole, left caudate, right superior temporal, left middle frontal and left superior occipital showed significantly increased ALFF in the NMO. Regions of abnormal fALFF were similar to those of ALFF except that increased fALFF were also indicated in the right cerebellum crus2, right hippocampus, left parahippocampal gyrus and left supplementary motor area. Furthermore, a significant correlation between EDSS scores and ALFF/fALFF was noted in the left inferior temporal gyrus.

CONCLUSION

Results confirmed the disturbances in NMO-related neural networks, which probably be related to spinal cord damage.

Dietary total antioxidant capacity and neuromyelitis optica spectrum disorder susceptibility

Purpose

Neuromyelitis Optica Spectrum Disorder (NMOSD) is a rare disease with unknown risk factors. The role of oxidative stress and nutritional factors is imprecise in NMOSD development. Therefore, this paper aims to evaluate the effects of dietary total antioxidant capacity (TAC) on the odds of NMOSD.

Design/methodology/approach

Dietary TAC was determined in 70 definite NMOSD cases and 164 healthy controls in term of Ferric Reducing Antioxidant Power (FRAP) method. A validated 168-item semi-quantitative food frequency questionnaire (FFQ) was used for dietary assessment. Three multivariate regression models were applied to analyze the odds of NMOSD across the TAC quartiles.

Findings

A significant inverse association was found between dietary TAC and odds of being assigned to the NMOSD group in all three regression models. In the fully adjusted model ORs (95% CI) in the second, third and fourth quartiles of TAC vs the first quartile were as follows: 0.11 (0.04-0.29), 0.05 (0.01-0.16) and 0.01 (0.00-0.05), respectively. Odds of NMOSD also indicated a significant decreasing trend across the quartiles of dietary TAC (p-trend: <0.01). Total energy (p < 0.01) as well as consumption of vegetables (p < 0.01), whole grains (p < 0.01), tea and coffee (p < 0.01), legumes (p < 0.01) and poultry (p < 0.01) significantly increased through the TAC quartiles.

Originality/value

In the present study, a new hypothesis was proposed concerning the influence of dietary TAC on the odds of NMOSD. A diet rich in foods with high TAC can be effective in the modification of the NMOSD odds.

The mediating effect of health-related hardiness on the degree of physical disability and perceived stress in Chinese female patients with neuromyelitis optica spectrum disorder

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is a rare and chronic disease of the central nervous system. The characteristics and main symptoms of recurrent NMOSD lead to an increase in psychological stress and accelerate a decline in the patients' quality of life. The incidence of NMOSD in the Chinese population is much higher than that for other countries and the majority of NMOSD patients are female. In general, there are sex differences in the perception and management of stress, with females experiencing higher levels of perceived stress than males. Thus, we should be concerned about the psychological issues experienced by Chinese female NMOSD patients. Health-related hardness is a psychological adjustment factor that could affect perceptions of illness that impact on NMOSD patients. The objective of this study was to evaluate the mediating role of health-related hardiness on physical disability and perceived stress in Chinese NMOSD female patients.

METHODS

Participants were 68 females patients with NMOSD treated at the Department of Neurology, Huashan Hospital, Fudan University, China, between March and September 2018. Patients were evaluated for their degree of physical disability, perceived stress, and health-related hardiness. Measures included the Expanded Disability Status Scale (EDSS), Perceived Stress Scale (PSS), and Health-related Hardiness Scale (HRHS). Pearson's correlation analyses and stepwise multiple linear regression analysis were used.

RESULTS

Findings indicated a positive correlation between the PSS and EDSS (r = 0.735, P < 0.001) and a negative correlation between the PSS and HRHS total score (r = -0.441, P < 0.001). After adjusting for the confounding factors, the EDSS was found to have a positive predictive effect on the PSS (β = 2.743, P = 0.000), and the HRHS was found to have a negative predictive effect on the PSS (β = -0.152, P = 0.04). Mediation analysis showed a direct effect of the EDSS on the PSS, and as a mediating variable for health-related hardiness (α = -1.928, b = -0.152, c = 2.743, c' = 2.481), which was statistically significant (P < 0.05). The mediating effect of health-related hardiness accounted for 10.68% of the total effect.

CONCLUSIONS

As a mediating variable, health-related hardiness indirectly affected perceived stress caused by physical disability and improved health-related hardiness. This was beneficial in reducing psychological stress and promoting mental health in NMOSD female patients.

Novel Molecular Leads for the Prevention of Damage and the Promotion of Repair in Neuroimmunological Disease

Neuroinflammation is a prominent pathological feature of all neuroimmunological diseases, including, but not limited to, multiple sclerosis (MS), myasthenia gravis, neuromyelitis optica, and Guillain–Barré syndrome. All currently-approved therapies for the treatment of these diseases focus on controlling or modulating the immune (innate and adaptive) responses to limit demyelination and neuronal damage. The primary purpose of this review is to detail the pre-clinical data and proposed mechanism of action of novel drugs currently in clinical trial, with a focus on novel compounds that promote repair and regeneration in the central nervous system (CNS). As the most recent advances have been made in the field of MS research, this review will focus primarily on this disease and its animal models. However, these compounds are likely to be effective for a range of indications with a neuroinflammatory component. Traditionally, MS was thought to proceed through two distinct phases. The first, predominantly inflammatory stage, is characterized by acute episodes of clinical relapse, followed by periods of partial or total recovery with an apparent absence of overall disease progression. In the vast majority of patients, this relapsing-remitting disease subsequently progresses into a second more chronic, neurodegenerative phase, which is characterized by oligodendrocyte damage and axonal destruction leading to brain atrophy and an accumulation of disability. Recent work has shown that rather than occurring independently, both the inflammatory and degenerative phases may run concurrently. This, combined with evidence that early therapeutic intervention slows accumulation of disability and delays progression, highlights the need for novel therapeutic approaches that promote repair and regeneration early in the disease trajectory. Such compounds may be used as monotherapies or in conjunction with classical anti-inflammatory therapies. This review will highlight novel therapies currently in clinical trial, and likely to appear in clinical practice in the near future, focusing on compounds that target the immune system and/or enhance endogenous repair mechanisms in the CNS.

Area Postrema: Fetal Maturation, Tumors, Vomiting Center, Growth, Role in Neuromyelitis Optica

INTRODUCTION

The area postrema in the caudal fourth ventricular floor is highly vascular without blood-brain or blood-cerebrospinal fluid barrier. In addition to its function as vomiting center, several others are part of the circumventricular organs for vasomotor/angiotensin II regulation, role in neuromyelitis optica related to aquaporin-4, and somatic growth and appetite regulation. Functions are immature at birth. The purpose was to demonstrate neuronal, synaptic, glial, or ependymal maturation in the area postrema of normal fetuses. We describe three area postrema tumors.

METHODS

Sections of caudal fourth ventricle of 12 normal human fetal brains at autopsy aged six to 40 weeks and three infants aged three to 18 months were examined. Immunocytochemical neuronal and glial markers were applied to paraffin sections. Two infants with area postrema tumors and another with neurocutaneous melanocytosis and pernicious vomiting also studied.

RESULTS

Area postrema neurons exhibited cytologic maturity and synaptic circuitry by 14 weeks'. Astrocytes coexpressed vimentin, glial fibrillary acidic protein, and S-100β protein. The ependyma is thin over area postrema, with fetal ependymocytic basal processes. A glial layer separates area postrema from medullary tegmentum. Melanocytes infiltrated area postrema in the toddler with pernicious vomiting; two children had primary area postrema pilocytic astrocytomas.

CONCLUSIONS

Although area postrema is cytologically mature by 14 weeks, growth increases and functions mature during postnatal months. We recommend neuroimaging for patients with unexplained vomiting and that area postrema neuropathology includes synaptophysin and microtubule-associated protein-2 in patients with suspected dysfunction.

NEUROMYELITIS OPTICA SPECTRUM DISORDERS: DIAGNOSIS AND TREATMENT, THE EXPERIENCE OF CLINICAL OBSERVATIONS

Neuromyelitis optica spectrum disorder (NMOSD) is an aggregate of inflammatory and autoimmune disorders of the central nervous system characterized by recurrent, disabling clinical course and damages predominantly targeting optic nerves, brain stem and spinal cord. NMOSD is stratified into two types: seropositive for aquaporin-4 antibodies (AQP4-IgG) and seronegative, which is reported in 25 % of cases. This article presents modern conceptualizations of NMOSD and describes authors’ own experience of clinical observation of patients.

Involvement of Aquaporins in the Pathogenesis, Diagnosis and Treatment of Sjögren's Syndrome

Sjögren’s syndrome (SS) is a chronic autoimmune disease characterized by lymphocytic infiltration of salivary and lacrimal glands resulting in diminished production of saliva and tears. The pathophysiology of SS has not yet been fully deciphered. Classically it has been postulated that sicca symptoms in SS patients are a double step process whereby lymphocytic infiltration of lacrimal and salivary glands (SG) is followed by epithelial cell destruction resulting in keratoconjunctivitis sicca and xerostomia. Recent advances in the field of the pathophysiology of SS have brought in new players, such as aquaporins (AQPs) and anti AQPs autoantibodies that could explain underlying mechanistic processes and unveil new pathophysiological pathways offering a deeper understanding of the disease. In this review, we delineate the link between the AQP and SS, focusing on salivary glands, and discuss the role of AQPs in the treatment of SS-induced xerostomia.

Treating neuromyelitis optica with azathioprine: 20-year clinical practice

BACKGROUND

Neuromyelitis optica leads to severe disability. Preventive treatment includes steroids and immunosuppressants, and indications are based on retrospective and observational studies.

METHODS

We analyzed 158 patients with neuromyelitis optica regarding disease course, prognostic factors, and treatment response to azathioprine, a widely available low-cost drug. Disability accumulation was used as an endpoint to treatment response.

RESULTS

Eight patients with monophasic and 150 with relapsing disease with a median 7 years of disease duration and 4.6 years of follow-up were evaluated. All relapsing patients received preventive treatment, 100 with azathioprine. Only 30% reached Expanded Disability Status Scale (EDSS) 6, and 69% of patients presented no disability accumulation along follow-up. The time under azathioprine and prednisone use were inversely correlated to the hazard of disability accumulation (hazard ratio (HR) = 0.981 and 0.986, respectively; p < 0.01). Each month under azathioprine use reduced disability accumulation by 2.6% (HR = 0.974, p < 0.01), corresponding to an 80% decrease in EDSS progression over 5 years.

INTERPRETATION

We report less disability accumulation than previous series on patients with neuromyelitis optica, two-thirds presenting no disability accumulation along follow-up. Continued azathioprine used from early disease onset was strongly associated to maintenance of neurological function and should be offered as a viable option for low-income scenarios.