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Popescu BFG, Guo Y, Jentoft ME, Parisi JE, Lennon VA, Pittock SJ, Weinshenker BG, Wingerchuk DM, Giannini C, Metz I, Brück W, Shuster EA, Carter J, Boyd CD, Clardy SL, Cohen BA, Lucchinetti CF. Diagnostic utility of aquaporin-4 in the analysis of active demyelinating lesions. Neurology 2014; 84:148-58. [PMID: 25503621 DOI: 10.1212/wnl.0000000000001126] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To assess, in a surgical biopsy cohort of active demyelinating lesions, the diagnostic utility of aquaporin-4 (AQP4) immunohistochemistry in identifying neuromyelitis optica (NMO) or NMO spectrum disorder (NMOSD) and describe pathologic features that should prompt AQP4 immunohistochemical analysis and AQP4-immunoglobulin G (IgG) serologic testing. METHODS This was a neuropathologic cohort study of 20 surgical biopsies (19 patients; 11 cord/9 brain), performed because of diagnostic uncertainty, interpreted as active demyelinating disease and containing 2 or more of the following additional features: tissue vacuolation, granulocytic infiltrates, or astrocyte injury. RESULTS AQP4 immunoreactivity was lost in 18 biopsies and increased in 2. Immunopathologic features of the AQP4 loss cohort were myelin vacuolation (18), dystrophic astrocytes and granulocytes (17), vascular hyalinization (16), macrophages containing glial fibrillary acid protein (GFAP)-positive debris (14), and Creutzfeldt-Peters cells (0). All 14 cases with available serum tested positive for AQP4-IgG after biopsy. Diagnosis at last follow-up was NMO/NMOSD (15) and longitudinally extensive transverse myelitis (1 each relapsing and single). Immunopathologic features of the AQP4 increased cohort were macrophages containing GFAP-positive debris and granulocytes (2), myelin vacuolation (1), dystrophic astrocytes (1), Creutzfeldt-Peters cells (1), and vascular hyalinization (1). Diagnosis at last follow-up was multiple sclerosis (MS) and both tested AQP4-IgG seronegative after biopsy. CONCLUSIONS AQP4 immunohistochemistry with subsequent AQP4-IgG testing has diagnostic utility in identifying cases of NMO/NMOSD. This study highlights the importance of considering NMOSD in the differential diagnosis of tumefactive brain or spinal cord lesions. AQP4-IgG testing may avert biopsy and avoid ineffective therapies if these patients are erroneously treated for MS.
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Affiliation(s)
- Bogdan F G Popescu
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Yong Guo
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Mark E Jentoft
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Joseph E Parisi
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Vanda A Lennon
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Sean J Pittock
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Brian G Weinshenker
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Dean M Wingerchuk
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Caterina Giannini
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Imke Metz
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Wolfgang Brück
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Elizabeth A Shuster
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Jonathan Carter
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Clara D Boyd
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Stacey Lynn Clardy
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Bruce A Cohen
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL
| | - Claudia F Lucchinetti
- From the Department of Anatomy and Cell Biology and Cameco MS Neuroscience Research Center (B.F.G.P.), University of Saskatchewan, Saskatoon, Canada; the Departments of Neurology (Y.G., J.E.P., V.A.L., S.J.P., B.G.W., S.L.C., C.F.L.), Laboratory Medicine and Pathology (M.E.J., J.E.P., V.A.L., S.J.P., G.G.), and Immunology (V.A.L.), Mayo Clinic, Rochester, MN; the Department of Neurology (D.M.W., J.C.), Mayo Clinic, Scottsdale, AZ; the Department of Neuropathology (I.M., W.B.), University Medical Center, Georg August University, Göttingen, Germany; the Department of Neurology (E.A.S.), Mayo Clinic, Jacksonville, FL; the Department of Neurology (C.D.B.), Columbia University Medical Center, New York, NY; and the Department of Neurology (B.A.C.), Feinberg School of Medicine, Northwestern University, Evanston, IL.
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