A serum autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis

Distinguishing Neuromyelitis Optica Spectrum Disorders Subtypes: A Study on AQP4 and C3d Epitope Expression in Cytokine-Primed Human Astrocytes

Neuromyelitis optica spectrum disorders (NMOSD) are severe autoimmune conditions affecting the central nervous system. In a subset of cases, no autoantibodies are detectable with the currently used routine assays. This study aimed to determine whether the levels of expression of aquaporin-4 (AQP4), excitatory amino acid transporter 2 (EAAT2), or complement C3/C3d and C5b-9 in human astrocytes following incubation with patient sera under inflammatory conditions differ between the various NMOSD subtypes and whether such differences can help to identify autoantibody-mediated cases of NMOSD. Levels of AQP4, EAAT2, complement C3/C3d and C5b-9 epitope expression on human astrocytes pretreated with various cytokines were quantitatively analyzed via indirect immunofluorescence after exposure to sera from patients with AQP4-IgG seropositive, MOG-IgG seropositive, and AQP4/MOG-IgG double seronegative NMOSD. Significant differences in AQP4 and C3d epitope expression were observed, with IL-17A, IL-10, and IL-6 pre-treatment notably influencing astrocytic responses. Using uniform manifold approximation and projection (UMAP), patients were classified into clusters corresponding to AQP4-IgG seropositive, MOG-IgG seropositive, or double seronegative NMOSD. These results demonstrate distinct astrocytic staining patterns across NMOSD subtypes, providing a potential diagnostic tool for distinguishing between autoantibody-mediated astrocytopathy and other cases. These findings suggest specific pathogenic mechanisms linked to each NMOSD subtype, which may have implications for tailoring therapeutic strategies based on cytokine involvement and astrocyte reactivity.

Distinct prognostic implications of blood neuronal and astroglial biomarkers in neuromyelitis optica spectrum disorders versus multiple sclerosis

Research on neuronal and astroglial markers for predicting outcomes in aquaporin-4 antibody-seropositive neuromyelitis optica spectrum disorders (NMOSD) remains limited. We aimed to evaluate the prognostic value of blood biomarkers for neuronal and astroglial damage in NMOSD compared with multiple sclerosis (MS). Patients with NMOSD and MS were prospectively recruited, and baseline serum levels of neurofilament light (sNfL) and glial fibrillary acidic protein (sGFAP) were measured. The correlations between these biomarkers and neurological disability (Expanded Disability Status Scale, EDSS) and cognitive function (iPad-based processing speed test, PST) were analyzed at baseline and two years later. In this cohort of 41 NMOSD and 92 MS patients, blood biomarkers demonstrated distinct patterns of association with current and future outcomes. In NMOSD, sGFAP was consistently linked to neurological disability and cognitive impairment over time, reflecting astrocytopathy with minimal silent neurodegeneration. In MS, sGFAP did not correlate with baseline EDSS but showed associations with future scores. Notably, sNfL was more strongly associated with future PST scores than baseline scores (p = 0.005), suggesting ongoing neurodegeneration. These results underscore that blood biomarkers are predictive of both current and future outcomes in NMOSD and MS, with differing patterns reflecting the unique pathogenesis of each disease.

Effect of L-Carnitine Level on the Risk of Neuromyelitis Optica Spectrum Disorders: A Two-Sample Mendelian Randomization Study

Previous research has often focused on studying the CNS damage in neuromyelitis optica spectrum disorders (NMOSD), while the role of the peripheral blood in the development of NMOSD is also of significant importance. The relationship between metabolites in blood and cerebrospinal fluid (CSF) with neuroimmune is receiving increasing attention. L-carnitine, whose astrocytic accumulation is associated with neuroinflammation and demyelination, may participate in the pathogenesis of NMOSD. However, whether circulating L-carnitine level has a causal effect on NMOSD risk needs elucidation. With large data sets now available, we used two-sample Mendelian randomization (MR) to determine whether circulating L-carnitine level is causally associated with the risk of NMOSD. Genetic variants associated with circulating L-carnitine levels were derived from a genome-wide association study (GWAS) of 7797 individuals from TwinsUK and KORA F4 cohorts. NMOSD summary statistics, including 215 cases and 1244 controls, were obtained from a separate GWAS. Subgroup analyses included aquaporin-4 (AQP4)-IgG-seropositive NMOSD (132 cases) and AQP4-IgG-seronegative NMOSD (83 cases). We used two-sample MR to explore associations between circulating L-carnitine levels and NMOSD risk, as well as its seropositive and seronegative subtypes. 16 SNPs (single nucleotide polymorphisms) were significantly associated with circulating L-carnitine level (P < 5 × 10-8), all of which were independent and available in the NMOSD dataset, after 1 SNP removed for being palindromic with intermediate allele frequencies in harmonization. Finally, a high circulating L-carnitine level conferred a protective effect against combined NMOSD (OR = 2.216 × 10-4, 95% confidence interval [CI] = 2.335 × 10-7-2.104 × 10-1, P = 0.0161) as well as AQP4-IgG-seronegative NMOSD (OR = 7.678 × 10-7, 95% CI = 2.233 × 10-11-2.640 × 10-2, P = 0.0082). There is no causal effect on AQP4-IgG-seropositive NMOSD risk (OR = 5.471 × 10-3, CI = 1.090 × 10-6-27.465, P = 0.2798) by circulating L-carnitine. Results remained positive and robust after the horizontal pleiotropy test, heterogeneity test, and Bonferroni test. In the reverse MR analysis, there was no causal effect of NMOSD and its subtypes on circulating L-carnitine levels. Our findings suggest that higher circulating L-carnitine levels may reduce the risk of NMOSD, particularly in AQP4-IgG-seronegative patients. L-carnitine could serve as a valuable biomarker and potential therapeutic target for NMOSD, especially in cases without AQP4-IgG. The genetic evidence from this study supports further exploration of L-carnitine's role in managing NMOSD.

Optic Neuritis

OBJECTIVE

This article reviews the most common and noteworthy inflammatory and infectious optic neuropathies, with an update on newer syndromes.

LATEST DEVELOPMENTS

We have entered an era of antibody-assisted definitions of distinct types of optic neuritis, including aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein-associated disease, with distinct pathophysiologies, prognoses, and management options. It is crucial to distinguish between these entities and other common inflammatory (eg, sarcoid or other granulomatous inflammation) or infectious optic neuropathies as appropriate therapy radically differs. These developments highlight the increasing importance of precision terminology as many of these now distinctly defined syndromes have been previously lumped together as "typical or atypical optic neuritis." An individualized evaluation and treatment approach is required.

ESSENTIAL POINTS

Multiple sclerosis-related optic neuritis is the most common form of inflammatory demyelinating optic neuritis, causing short segments of optic nerve inflammation, with an excellent visual prognosis and tendency to improve with or without high-dose steroids.Aquaporin-4 associated optic neuritis causes longitudinally extensive optic nerve inflammation and has a more guarded prognosis for visual recovery, with poor visual outcomes in untreated patients compared with multiple sclerosis or myelin oligodendrocyte glycoprotein-associated disease.Myelin oligodendrocyte glycoprotein optic neuritis also causes longitudinally extensive optic nerve inflammation with a predilection for optic disc edema and tends to be very steroid sensitive, but recurrent. Infectious optic neuropathies are important to recognize; syphilis incidence has doubled in the last decade and requires early aggressive therapy to maximize visual recovery.

Osteopontin Regulates AQP4 Expression by TRPV4 Activation in Müller Cells: Implications for Retinal Homeostasis

During the intense neuronal activity in the retina, Müller cells are exposed to a hypotonic environment and activate a regulatory volume decrease (RVD) response, which depends on Aquaporin-4 (AQP4) and the calcium channel Transient Receptor Potential Vanilloid 4 (TRPV4). It was reported that Osteopontin (OPN), a cytokine and component of the extracellular matrix (ECM), may modulate the RVD of Müller cells. In other cell types, OPN participates in cell survival and migration, which Müller cells undergo to maintain retinal homeostasis. Therefore, the aim of this work was to study the putative crosstalk of OPN with AQP4 and/or TRPV4 in the main functions of Müller cells: RVD, morphology maintenance and migration. We used a human Müller cell line (MIO-M1) exposed to OPN and evaluated cell volume and osmotic permeability (Pf) during an osmotic swelling, AQP4 expression, cell morphology and migration. We observed that OPN induced a reduced Pf and RVD by downregulating AQP4 expression, which was prevented by TRPV4 inhibition. OPN also induced significant changes in cell morphology with an increased number of cytoplasmic projections. Finally, OPN reduced the migration of Müller cells, being this effect dependent on TRPV4. We propose that OPN affects water permeability and cell volume regulation of Müller cells by activating TRPV4 to reduce AQP4 expression. This represents a novel mechanism of regulation of water permeability by the ECM in Müller cells. Additionally, OPN-induced changes in morphology and migration of Müller cells may have an impact on retinal physiology.

Effectiveness and safety of therapeutic plasma exchange in neurological diseases: An 11-year report from a tertiary care center

BACKGROUND

Therapeutic plasma exchange has been a well-known treatment method for many years and is widely available. It leads to the improvement of neurological symptoms in autoimmune neurological diseases by the removal of antibodies. The aim of this study was to present therapeutic plasma exchange responses and procedure-related adverse events in patients with autoimmune neurological diseases based on our 11-year experience.

METHOD

A retrospective evaluation was conducted on adult patients who underwent a therapeutic plasma exchange procedure due to neurological diseases between January 2013 and January 2024. Data were gathered from electronic and written hospital and apheresis unit records.

RESULTS

A total of 265 patients underwent 1274 procedures with a preliminary diagnosis of autoimmune neurological disease. Five patients were excluded from the analysis due to their final diagnoses. The most common clinical indications were Guillain-Barré syndrome (45.4%), myasthenia gravis (26.1%), and multiple sclerosis (19.2%). The overall response rate was 81.3%, with 21.7% exhibiting a complete response and 59.6% demonstrating a partial response. With the exception of one patient (hypertensive crisis), no complications necessitating the termination of the procedure were observed. The most prevalent complication was an easily manageable allergic reaction.

CONCLUSION

Therapeutic plasma exchange has been demonstrated to be an efficacious and safe treatment option in autoimmune neurological diseases, with a favorable overall response rate and a manageable mild-to-moderate side effect profile.

Differences in clinical phenotype, laboratory, and imaging manifestations between AQP4 IgG positive and AQP4 MOG IgG double negative NMOSD: How to correctly diagnose the two

Neuromyelitis optica spectrum disorders (NMOSD) is an uncommon autoimmune inflammatory demyelinating disorder of the central nervous system (CNS) and causes severe disability and even death. Aquaporin-4 immunoglobulin G (AQP4-IgG) antibody has been confirmed as the key pathogenic factor for development of NMOSD and leading to repeatting acute attacks. However, 20-40 % of NMOSD patients lack both AQP4-IgG and anti-myelin oligodendrocytes glycoproteins (MOG) IgG, in which the pathogenic factor is still unclear. There are differences in clinical, laboretory and imaiging minifestations between AQP4-IgG positive (AQP4-IgG+) and AQP4-IgG/MOG-IgG double negative (AQP4-IgG-) NMOSD. Although the treatments applied in NMOSD have made great progress, all treatments are failed in AQP4-IgG- patients. Additionally, it is hard to identify NMOSD with AQP4-IgG- from multiple sclerosis (MS). Therefore, it is suspected and challenged that AQP4-IgG could not be the only pathogenic factor in NMOSD or NMOSD with AQP4-IgG- may be a separate disorder independent of NMOSD AQP4-IgG+? It is necessary to find more pathogenic factors and to explore the new pathogenesis and treatments of NMOSD with AQP4-IgG- in the future, which has been a serious problem to be addressed by the neurology community.

Single-electrode electrochemiluminescence immunosensor for multiplex detection of Aquaporin-4 antibody using metal-organic gels as coreactant

Reliable detection of Aquaporin-4 (AQP4) antibodies is crucial for diagnosing Neuromyelitis Optica spectrum disorder (NMOSD). However, cell-based assays, the most reliable approach, are limited by inadequate instruments. This study reports the use of silver metal-organic gels (Ag-MOGs) as coreactants in a single-electrode electrochemical system (SEES)-based electrochemiluminescence (ECL) immunosensor for multiplex detection of AQP4 antibodies. The immunosensor was constructed by modifying the carbon nanotube single-electrode with Ag-MOGs, incubating it with AQP4 peptides, and ultimately enabling the immobilization of AQP4 antibodies. Voltage-induced potential gradients at the electrode triggered the Ru(bpy)32+ ECL reaction, and reduced emissions caused by AQP4 antibodies were recorded using a smartphone. Under optimal conditions, the immunosensor exhibited a strong linearity (10-1000 ng/mL) with a detection limit of 2.8 ng/mL. Validation of its accuracy, precision, dilutability, and selectivity confirmed robust performance across the diverse parameters. Furthermore, it successfully detected AQP4 antibodies in serum samples from seropositive NMOSD patients. The platform's single electrode design and multiplex capability make it simple, fast and cost-effective. Enhanced accessibility and user-friendliness could position this system as a transformative tool for improving disease diagnosis and treatment, particularly in resource-limited regions.

Proteome-Wide Analysis of Autoantibodies in Open-Angle Glaucoma in Japanese Population: A Pilot Study

Objectives: The objective of this study was to identify novel autoantibodies specific for open-angle glaucoma (OAG), including normal-tension glaucoma (NTG) and primary open-angle glaucoma (POAG), using proteome-wide autoantibody screening and to determine their utility for diagnosis. Methods: We conducted proteome-wide autoantibody screening by wet protein arrays. Autoantibody reactivity in the plasma of OAG patients (50 NTG and 69 POAG patients) was quantitatively analyzed and compared to that of controls (35 cataract patients). The area under the curve (AUC) of the receiver operating characteristic (ROC) and multivariate analyses were used to determine diagnostic potential in patients with OAG. Results: Based on differences in autoantibody titers and positivity rates, four autoantibodies against ETNK1, VMAC, NEXN, and SUN1 were selected as potential biomarkers to discriminate OAG and cataract. In discrimination between POAG and cataract, the AUCs of ETNK1 and VMAC were calculated to be 0.820 (95%CI: 0.733-0.907) and 0.889 (95%CI: 0.818-0.959), respectively. Furthermore, the combination of these four antibodies demonstrated diagnostic potential for OAG with an AUC of 0.828 (95%CI: 0.757-0.898) by multivariate analysis. Conclusions: Four new glaucoma-associated autoantibodies were identified in this study. The differences in autoantibody patterns in the plasma between glaucoma and cataract patients support their potential utility as biomarkers for glaucoma screening.

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD): Insights into pathogenesis and biomarkers of prognosis

MOG antibody-associated disease (MOGAD), an inflammatory demyelinating pathology, is typically associated with the clinical phenotypes acute disseminated encephalomyelitis (ADEM), optic neuritis (ON), or transverse myelitis (TM). The mainstay of diagnosis is detection of antibodies targeting oligodendrocyte-expressed MOG (MOG-IgG). MOG-IgG-mediated demyelination occurs via complement-dependent cytotoxicity (CDC), antibody-dependent cellular cytotoxicity (ADCC), enhanced cognate T-cell CNS infiltration and activation, and oligodendrocyte cytoskeleton disruption, but the exact role of the immune system in MOGAD is still poorly understood. The disease course is either monophasic or relapsing, with relapsing course affecting approximately two-thirds of individuals. Neurological disability accumulates with relapse and may manifest as visual, motor, sensory, and cognitive deficits. Thus, accurate disease course prediction is of paramount importance. Prognostic biomarkers, implemented at a global scale, have the potential to guide timely therapeutic decisions to limit relapse-associated disability accrual while simultaneously avoiding unnecessary immunosuppression in monophasic individuals. This review explores recent insights in the understanding of MOGAD pathogenesis as well as advances in prognostic biomarkers of relapsing course and disease activity.

Comparison of the clinical and laboratory characteristics of neuromyelitis optica spectrum disorder with or without cerebrospinal fluid oligoclonal bands: a cohort with 36-month follow-up

Purpose

This study aimed to explore the significance of cerebrospinal fluid (CSF) oligoclonal bands (OCBs) in the clinical diagnosis and evaluation of neuromyelitis optica spectrum disorder (NMOSD).

Methods

The demographic and clinical data of 143 aquaporin-4 immunoglobulin G (AQP4-IgG)-positive NMOSD patients were collected and analyzed, including the gender, age, clinical symptoms and signs, status of CSF OCBs, location and length of the affected spinal cord vertebral segments, Expanded Disability Status Scale (EDSS) at the first attack and at 36-month follow-up, relapse times within 36 months, concomitant connective tissue disease (CTD), and status of other autoimmune antibodies (oAIA).

Results

There were 15 patients (10.5%) who were positive for OCBs (OCBs+). In contrast to those with negative OCBs (OCBs-), more OCBs+ cases had concomitant CTD [5/15 (33.3%) vs. 11/128 (8.6%), p = 0.014] and oAIA [9/15 (60.0%) vs. 37/128 (28.9%), p = 0.020]. OCBs+ patients had higher CSF cell counts [15.0 (27.0)/mm3 vs. 5.0 (12.0)/mm3, p = 0.008], higher IgG index [0.68 (0.23) vs. 0.52 (0.15), p < 0.001], and more relapses within 36 months [2.0 (3.0) vs. 1.0 (2.0), p = 0.039] than OCBs- patients. More OCBs+ patients had polynuclear cell predominance in the CSF than OCBs- patients (p = 0.032). There were no significant differences between the OCBs+ and the OCBs- patients in the distribution of lesion locations; the length of the affected spinal cord vertebral segments; the concentration of CSF protein and the albumin quotient; the EDSS score at the time of lumbar puncture and at 36-month follow-up, and the onset episode, the relapse, and cumulative clinical syndrome profiles (all p > 0.05).

Conclusions

For AQP4-IgG-positive NMOSD patients, positivity for CSF OCBs is associated with higher CSF cell counts and a higher likelihood to have concomitant CTD and oAIA. OCBs+ is not uncommon in NMOSD and may predict more frequent relapses, but not a more serious illness.

Serum Lipid Biomarkers for the Diagnosis and Monitoring of Neuromyelitis Optica Spectrum Disorder: Towards Improved Clinical Management

Background

Neuromyelitis optica spectrum disorder (NMOSD) is a group of immune-mediated disorders that often lead to severe disability. The diagnosis and monitoring of NMOSD can be challenging, particularly in seronegative cases, highlighting the need for reliable biomarkers to enhance clinical management. This study aimed to identify serum lipid biomarkers for the diagnosis and monitoring of NMOSD and to assess their potential to improve clinical decision-making.

Methods

We conducted a comprehensive serum proteomic analysis in a discovery cohort of NMOSD patients and controls to identify lipid-related proteins associated with NMOSD. Subsequently, we validated the candidate biomarkers in the retrospective cohort and developed diagnostic models using a random forest algorithm. The association between these lipid biomarkers and disease activity was further evaluated in longitudinal analysis.

Results

Our analysis identified a panel of serum lipid-related biomarkers that demonstrated significant differences between NMOSD patients and controls. The diagnostic models achieved the impressive accuracy of 72% for the full NMOSD spectrum, 72% for AQP4-IgG+ NMOSD, and 68% for double seronegative NMOSD. Importantly, these biomarkers showed a correlation with disease activity, with levels changing from relapse to remission. Additionally, a combination of these lipid biomarkers was found to predict relapse with the AUC of 0.861. A user-friendly smartphone application was developed to facilitate the straightforward "input-index, output-answer" screening process, enhancing both clinical decision-making and patient care.

Conclusion

The diagnostic model based on the serum lipid-related indexes (TC, TG, LDL, HDL, ApoA1, and ApoB) may be the useful tool for NMOSD in diagnosis and monitoring of disease stage, thereby improving the treatment outcome for patients. Future studies should focus on integrating these biomarkers into routine clinical practice to realize their full potential in enhancing NMOSD management.

Contribution of germline and somatic mutations to risk of neuromyelitis optica spectrum disorder

Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune disease characterized by optic neuritis and transverse myelitis, with an unclear genetic background. A genome-wide meta-analysis of NMOSD in Japanese individuals (240 patients and 50,578 controls) identified significant associations with the major histocompatibility complex region and a common variant close to CCR6 (rs12193698; p = 1.8 × 10-8, odds ratio [OR] = 1.73). In single-cell RNA sequencing (scRNA-seq) analysis (25 patients and 101 controls), the CCR6 risk variant showed disease-specific expression quantitative trait loci effects in CD4+ T (CD4T) cell subsets. Furthermore, we detected somatic mosaic chromosomal alterations (mCAs) in various autoimmune diseases and found that mCAs increase the risk of NMOSD (OR = 3.37 for copy number alteration). In scRNA-seq data, CD4T cells with 21q loss, a recurrently observed somatic event in NMOSD, showed dysregulation of type I interferon-related genes. Our integrated study identified novel germline and somatic mutations associated with NMOSD pathogenesis.

Current state and perspectives of CAR T cell therapy in central nervous system diseases

B cell-directed CAR T cell therapy has fundamentally changed the treatment of haematological malignancies, and its scope of application is rapidly expanding to include other diseases such as solid tumours or autoimmune disorders. Therapy-refractoriness remains an important challenge in various inflammatory and non-inflammatory disorders of the CNS. The reasons for therapy failure are diverse and include the limited access current therapies have to the CNS, as well as enormous inter- and intra-individual disease heterogeneity. The tissue-penetrating properties of CAR T cells make them a promising option for overcoming this problem and tackling pathologies directly within the CNS. First application of B cell-directed CAR T cells in neuromyelitis optica spectrum disorder and multiple sclerosis patients has recently revealed promising outcomes, expanding the potential of CAR T cell therapy to encompass CNS diseases. Additionally, the optimization of CAR T cells for the therapy of gliomas is a growing field. As a further prospect, preclinical data reveal the potential benefits of CAR T cell therapy in the treatment of primary neurodegenerative diseases such as Alzheimer's disease. Considering the biotechnological optimizations in the field of T cell engineering, such as extension to target different antigens or variation of the modified T cell subtype, new and promising fields of CAR T cell application are rapidly opening up. These innovations offer the potential to address the complex pathophysiological properties of CNS diseases. To use CAR T cell therapy optimally to treat CNS diseases in the future while minimizing therapy risks, further mechanistic research and prospective controlled trials are needed to assess seriously the disease and patient-specific risk-benefit ratio.

Cerebrospinal fluid interleukin-6 may be a biomarker for conversion of clinically isolated syndrome to neuromyelitis optica spectrum disorder

OBJECTIVE

To evaluated the predictive value of several cerebrospinal fluid (CSF) cytokines in the conversion of clinically isolated syndrome (CIS) patients to neuromyelitis optica spectrum disorder (NMOSD) or multiple sclerosis (MS).

METHODS

We enrolled 33 CIS patients whose CSF samples were collected during the acute phase of the first onset before immunotherapy. The CSF levels of interleukin (IL)-2, IL-4, IL-6, IL-10, IL-13, IL-17A, IL-21, IL-23, interferon-γ (IFN-γ) and transforming growth factor beta 1 (TGF-β1) were measured using the human cytokine multiplex assay or ELISA. Patients were seen every 3 to 6 months. Unscheduled visits occur in case of exacerbations. Clinical measures of disease progression were recorded.

RESULTS

The mean follow-up of CIS patients was 23.2 ± 7.9 months. Six patients converted to NMOSD, six patients converted to MS. The CSF IL-21 and IL-6 levels were significantly elevated in CIS patients converted to NMOSD than those who did not. High CSF IL-6 levels are a predictor of conversion to NMOSD in patients with CIS and are associated with a shorter time to conversion. Increased CSF IL-6 levels correlated with CSF WBC count, protein level and IgG index, segment of myelitis, EDSS scores. There was no significant difference in cytokine levels between patients who converted to MS and those who did not.

CONCLUSIONS

These findings validate CSF IL-6 as an independent predictive factor for the risk of clinical conversion to NMOSD in CIS. The above CSF cytokines levels in CIS patients can't predict conversion to MS.

Central American and Caribbean consensus for the treatment of MS, NMOSD, and MOGAD

BACKGROUND

In recent years, significant progress has been made in immune demyelinating disorders, particularly regarding early diagnosis and disease-modifying drugs (DMDs). Despite advancements, socioeconomic factors in many Latin American countries present unique challenges that impede the proper identification and management of these disorders.

OBJECTIVES

The updated consensus from the Central American and Caribbean working group strives to enhance the management of Multiple Sclerosis (MS), Neuromyelitis Optica Spectrum Disorder (NMOSD), and Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD) by offering a framework for incorporating available treatment into clinical practice.

METHODS

The authors conducted an extensive bibliographic search and followed a consensus process that included input from forum members to present a new, revised, and finalized report.

RESULTS

The consensus, endorsed by over 70% of members, covers the application of DMDs, biologic agents, glucocorticoids, definitions of therapeutic failure, patient monitoring, cessation of treatment, prognosis, therapy use during pregnancy and lactation, and vaccination in patients initiating or on DMDs or biologic treatments.

CONCLUSION

The revised consensus and guidelines aim to enhance long-term outcomes in these regions by assisting patients, regulatory bodies, healthcare providers, and policymakers.

Ravulizumab and other complement inhibitors for the treatment of autoimmune disorders

Ravulizumab (ULTOMIRIS™) an intravenous glycoengineered humanized anti-C5 IgG2/4 monoclonal antibody (mAb), is a new FDA-approved treatment for Aquaporin-4-antibody (AQP4-IgG) positive Neuromyelitis Optica Spectrum Disorder (NMOSD). Based on the importance of intermediate and terminal components of the complement cascade during disease pathogenesis, in the last few years, a mAb targeting the C5 complement factor (anti-C5, eculizumab) has already been in use for treating AQP4-IgG positive NMOSD. Ravulizumab acts similarly to eculizumab, binding specifically to the complement protein C5, thereby blocking the generation of the anaphylatoxin C5a and of C5b, which is crucial for generating the membrane attack complex (C5b-9). Here, we discuss the main findings obtained during the phase 3 clinical trial (CHAMPIONNMOSD [NCT0420126]) for ravulizumab and new developments in anti-complement therapy, with other complement inhibitors for the treatment of autoimmune diseases and paroxysmal nocturnal hemoglobinuria (PNH) (zilucoplan, avacopan and, pegcetacoplan). The approval of the new long-acting anti-C5 mAb adds another therapeutic option to the already existing inhibitors of complement currently in use, increasing therapeutic options for inflammatory and autoimmune diseases.

MRI-based radiomics for differention of aquaporin 4-immunoglobulin G-positive neuromyelitis optic spectrum disorder and anti myelin oligodendrocyte glycoprotein immunoglobulin G-associated disorder

OBJECTIVES

This study was designed to develop and validate a radiomic nomogram for the differential diagnosis of myelin oligodendrocyte glycoprotein antibody-related disease (MOGAD) and aquaporin-4 immunoglobulin G-positive neuromyelitis optica spectrum disorder (AQP4+NMOSD).

METHODS

We retrospectively analysed data from a primary cohort consisting of 21 MOGAD and 63 AQP4+NMOSD patients and an external validation cohort comprising 10 MOGAD and 34 AQP4+NMOSD patients. Radiomic features were extracted from lesions of the cervical spinal cord and brainstem from sagittal T2-weighted MR images. We constructed a prediction model by integrating radiomic features with clinical data and evaluated its performance using calibration curves and decision curve analysis (DCA).

RESULTS

We developed a comprehensive nomogram that combines clinical and radiomic features to distinguish MOGAD from AQP4+NMOSD. The discriminative ability of the nomogram was quantified by the area under the receiver operating characteristic (ROC) curve (AUC), achieving values of 0.915 (95 % CI, 0.859-0.970) in the primary cohort and 0.837 (95 % CI, 0.715-0.959) in the validation cohort, indicating high diagnostic accuracy. The calibration analyses showed good concordance between the model predicted and actual outcomes.

CONCLUSIONS

This study successfully validated the radiomic feature model, demonstrating its superior performance in differentiating MOGAD from AQP4+NMOSD. The nomogram, integrating radiomic features with conventional imaging characteristics of brainstem and cervical cord lesions, significantly enhanced differentiation capability. Both models proved valuable in improving diagnostic accuracy, with radiomic features contributing most significantly.

Advances in Diagnosis and Management of Atypical Demyelinating Diseases

The last two decades have seen tremendous progress in understanding central nervous system (CNS) demyelinating diseases, heralding an exciting new era for the diagnosis and treatment of patients with a variety of non-multiple sclerosis neuroinflammatory diseases. This article comprehensively reviews atypical CNS demyelinating diseases, beginning with the general approach to CNS demyelination, continuing with suggestions to facilitate the initial evaluation, and followed by a discussion about specific diseases (neuromyelitis optica, myelin oligodendrocyte glycoprotein antibody disease, acute disseminated encephalomyelitis, iatrogenic CNS demyelination, and transverse myelitis). MRI examples of these disorders are provided to illustrate key radiographic findings. The article concludes with recommendations for treatment.

Clinical characteristics of late-onset neuromyelitis optica spectrum disorder in China

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSD) are central nervous system demyelinating diseases that are distinct from multiple sclerosis. According to epidemiological studies, the incidence of NMSOD peaks in individuals aged 30-40 years. Therefore, whether the clinical manifestations and prognoses of NMOSD differ on the basis of age at onset is worthy of further investigation.

METHODS

The clinical, laboratory, and imaging data of NMOSD patients admitted to Peking University Third Hospital were retrospectively analyzed. EO-NMOSD was defined early onset NMOSD (age at onset < 50 years), and LO-NMOSD was defined as late onset NMOSD (age at onset > 50 years). Differences in clinical and imaging data were compared between the two groups.

RESULTS

A total of 75 patients with NMOSD were enrolled. Among them, 45 patients were age <50 years (EO-NMOSD), and 30 patients were age ≥ 50 years (LO-NMOSD). There was no significant difference in the EDSS score between the two groups at the time of onset (p = 0.071). The median EDSS scores at the last follow-up were 2 points and 3.5 points in the EO-NMOSD and LO-NMOSD groups, respectively, and the difference was statistically significant (p = 0.001). The proportions of patients with EDSS scores ≤ 3 points and 3 < EDSS scores ≤ 6 points were significantly different between the two groups (p = 0.023, p = 0.014), and there was no significant difference in the proportion of patients with EDSS scores greater than 6 points between the two groups (p = 1.000). Spearman correlation analysis revealed that age at onset was positively correlated with EDSS scores at onset (r = 0.284, p = 0.013) and EDSS scores at the last follow-up (r = 0.425, p = 0.000) and negatively correlated with the number of attacks (r = -0.280, p = 0.015). The proportion of AQP4-ab(+) patients with EDSS scores < 3 at onset was lower in the LO-NMOSD group than in the EO-NMOSD group (27.2 % vs. 59.5 %, p = 0.017), and the proportion of AQP4-ab(+) patients with 3 < EDSS scores ≤ 6 was greater in the LO-NMOSD group than in the EO-NMOSD group, both at onset (72.7 % vs. 32.4 %, p = 0.003) and at the last follow-up (54.5 % vs. 24.3 %, p = 0.019). In addition, the proportion of patients with hypertension in the AQP4-ab(+) group of patients with LO-NMOSD was significantly greater than that in the AQP4-ab(+) group of patients with EO-NMOSD (5.4 % vs. 27.3 %, p = 0.043).

CONCLUSION

LO-NMOSD patients, particularly those who were AQP4-ab positive, had more severe functional impairments and poorer prognoses. The number of attacks in AQP4-ab(+) patients with EO-NMOSD was greater than that in AQP4-ab(+) patients with LO-NMOSD.

Toward curing neurological autoimmune disorders: Biomarkers, immunological mechanisms, and therapeutic targets

Autoimmune neurology is a rapidly expanding field driven by the discovery of neuroglial autoantibodies and encompassing a myriad of conditions affecting every level of the nervous system. Traditionally, autoantibodies targeting intracellular antigens are considered markers of T cell-mediated cytotoxicity, while those targeting extracellular antigens are viewed as pathogenic drivers of disease. However, recent advances highlight complex interactions between these immune mechanisms, suggesting a continuum of immunopathogenesis. The breakdown of immune tolerance, central to these conditions, is affected by modifiable and non-modifiable risk factors such as genetic predisposition, infections, and malignancy. While significant therapeutic advancements have revolutionized treatment of certain diseases, such as neuromyelitis optica, our understanding of many others, particularly T cell-mediated conditions, remains limited, with fewer treatment options available. Future research should focus on improving effector function modeling and deepening our understanding of the factors influencing immune tolerance, with the goal of providing novel treatment options and improving patient care.

Transcriptome signature in the blood of neuromyelitis optica spectrum disorder under steroid tapering

Background

The advent of biologics has significantly transformed treatment strategies for neuromyelitis optica spectrum disorder (NMOSD). However, there are no biomarkers that predict relapses associated with steroid tapering; therefore, it is critical to identify potential indicators of disease activity. In this study, we collected peripheral blood mononuclear cells (PBMCs) from NMOSD patients during steroid tapering and performed bulk RNA sequencing to analyze changes in immune dynamics caused by steroid reduction.

Methods

PBMCs were collected at 3-5 timepoints from 10 NMOSD patients at our hospital (including one relapse case), and bulk RNA sequencing was performed. All patients were positive for anti-AQP4 antibodies and had no history of biologic use.

Results

In one relapsed patient, gene groups with decreased expression at relapse were observed predominantly in monocytes, with upregulation in anti-inflammatory pathways such as IL-10, while the upregulated genes were related to interferon signaling. Moreover, after steroid tapering, in non-relapsed patients, genes with increased expression were enriched in inflammatory pathways, represented by interferon signaling, while genes with decreased expression were enriched in pathways related to IL-10 and glucocorticoid receptors. Weighted gene co-expression network analysis identified modules that correlated with steroid dosage, and the modules inversely correlated with steroid dosage were enriched in monocytes, with marked immune signature of interferon pathway.

Conclusion

This study identified peripheral blood transcriptome signatures that could lead to the identification of clinically relevant NMOSD disease activity biomarkers, and further highlights the pivotal role of interferon and IL-10 signaling in NMOSD.

Aquaporin-4-IgG-seropositive neuromyelitis optica spectrum disorders: progress of experimental models based on disease pathogenesis

Neuromyelitis optica spectrum disorders are neuroinflammatory demyelinating disorders that lead to permanent visual loss and motor dysfunction. To date, no effective treatment exists as the exact causative mechanism remains unknown. Therefore, experimental models of neuromyelitis optica spectrum disorders are essential for exploring its pathogenesis and in screening for therapeutic targets. Since most patients with neuromyelitis optica spectrum disorders are seropositive for IgG autoantibodies against aquaporin-4, which is highly expressed on the membrane of astrocyte endfeet, most current experimental models are based on aquaporin-4-IgG that initially targets astrocytes. These experimental models have successfully simulated many pathological features of neuromyelitis optica spectrum disorders, such as aquaporin-4 loss, astrocytopathy, granulocyte and macrophage infiltration, complement activation, demyelination, and neuronal loss; however, they do not fully capture the pathological process of human neuromyelitis optica spectrum disorders. In this review, we summarize the currently known pathogenic mechanisms and the development of associated experimental models in vitro, ex vivo, and in vivo for neuromyelitis optica spectrum disorders, suggest potential pathogenic mechanisms for further investigation, and provide guidance on experimental model choices. In addition, this review summarizes the latest information on pathologies and therapies for neuromyelitis optica spectrum disorders based on experimental models of aquaporin-4-IgG-seropositive neuromyelitis optica spectrum disorders, offering further therapeutic targets and a theoretical basis for clinical trials.

Recommendations on NMOSD treatment in Latin America: Utilizing consensus-based RAND/UCLA methodology

INTRODUCTION

Neuromyelitis optica spectrum disorder (NMOSD) is a serious condition affecting people worldwide, including Latin America (LATAM). Healthcare disparities and economic limitations make effective treatment access challenging. It is crucial to consider the best practice therapeutic decision-making, including emerging long-term preventive therapies, to ensure patients in LATAM and elsewhere can effectively manage their disease all over the world.

OBJECTIVES/AIMS

To establish evidence-based guidelines for treatment approaches in NMOSD patients in LATAM. A consensus process was conducted to develop validated statements.

METHODS

A group of NMOSD experts from LATAM utilized a 9-point Likert scale to vote on statements related to NMOSD management. The predetermined consensus threshold was set at a minimum expert agreement of 70 %. The RAND/UCLA methodology was employed to reach consensus recommendations.

RESULTS

Nineteen experts completed the consensus process between March and April 2023. In round 1, no statement failed to reach the predetermined consensus, resulting in 31 agreed statements. The statements were divided between general recommendations (14/31) and clinical scenarios (17/31). The scenarios were based on treatment-naïve NMOSD AQP4 positive patients (4/17); treatment-naive seronegative NMOSD patients (4/17); treatment switching (5/17) and safety (4/17).

CONCLUSIONS

Consensus recommendations were developed on the most important areas of NMOSD treatment by a panel of experts in LATAM. These statements are a valuable tool to guide decision-making and improve patient outcomes, serving as the foundation for developing standardized practice guidelines in our region.

Etiological and clinical characterization of longitudinally extensive spinal cord lesions: A 12-year tertiary center experience

INTRODUCTION

Longitudinally extensive spinal cord lesions (LESCL) are characterized by T2-hyperintense signals spanning at least three vertebral body segments, with neuromyelitis optica spectrum disorders (NMOSD) being a significant cause. This study aimed to characterize the clinical, radiological, serological, and cerebrospinal fluid (CSF) features of LESCL and to compare NMOSD and non-NMOSD cases.

METHODS

We conducted a retrospective cross-sectional study of adult patients diagnosed with LESCL at our center over a twelve-year period collecting data on demographics, clinical presentations, MRI findings, CSF analysis, and serological testing for AQP4-IgG and MOG-IgG antibodies. Etiologies were reviewed based on current diagnostic criteria, with comparisons made between NMOSD and non-NMOSD LESCL.

RESULTS

We identified 41 LESCL cases, with NMOSD as the most common etiology (29.3 %) followed by ischemia (14.6 %) and multiple sclerosis (9.8 %). The median length of lesions was seven vertebral segments. Pleocytosis was present in 48.6 % of CSF analyses, with oligoclonal bands found in 10 cases. AQP4-IgG antibodies were positive in 11 of 12 NMOSD patients. NMOSD patients were more likely to be female (p = p.006), and exhibit severe symptoms, such as quadriparesis (p = 0.03) and a cervical sensory level (p = 0.04). MRI findings showed a preference for cervical lesions in NMOSD (p = 0.001) and thoracic lesions in non-NMOSD LESCL (p = 0.007).

CONCLUSIONS

LESCL exhibit considerable clinical diversity, with NMOSD being the predominant etiology. Characteristics such as female sex and cervical MRI involvement may indicate a higher likelihood of NMOSD, while cases in males with thoracic segment involvement may suggest non-NMSOD etiologies such as ischemia.

The atypical faces of optic neuritis: neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease

PURPOSE OF REVIEW

The purpose of this article is to provide a review of neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), with a focus on what renders optic neuritis "atypical" in these two conditions. Clinical features, diagnostic criteria, and epidemiology are outlined. Acute treatments for optic neuritis, as well as immunotherapy for NMOSD and MOGAD are discussed.

RECENT FINDINGS

Updates in NMOSD and MOGAD are highlighted, with an emphasis on novel work including the new 2023 MOGAD diagnostic criteria, our evolving understanding on the epidemiology of these conditions, and recently FDA-approved NMOSD treatments. Pipeline therapies are also discussed.

SUMMARY

A thorough history and examination, supported by ancillary testing, continues to be the mainstay of optic neuritis diagnosis. Stratifying typical versus atypical optic neuritis is paramount. Within the atypical category, NMOSD and MOGAD are important considerations. Clues can point towards these diagnoses and guide steps for treatment, which is increasingly becoming targeted to individual diseases, as the pathophysiology is different for these disorders.

Insights into neuromyelitis optica spectrum disorder and pregnancy from a single-center study in Thailand

Our study focused on assessing disease and pregnancy outcomes in Thai patients with Neuromyelitis Optica Spectrum Disorder (NMOSD), a condition that disproportionately affects women of childbearing age and poses risks to both mother and fetus. We retrospectively analyzed eight NMOSD patients with a total of 10 pregnancies from our central nervous system inflammatory demyelinating diseases (CNS-IDDs) registry. Over a 12-months spanning from before pregnancy to 12 months postpartum, we observed 13 relapses, with a notable 76.92% occurring postpartum. The mean annualized relapse rate (ARR) peaked at 1.2 (SD ± 1.93) during specific postpartum intervals (0-3 and 6-9 months postpartum), significantly increasing from 0.20 (SD ± 0.42) in the 12 months before pregnancy (BP) to 1.00 (SD ± 1.49) during the 12 months postpartum (PP). Disability, assessed using the Expanded Disability Status Scale (EDSS) scores, worsened from 1.56 (SD ± 2.18) before pregnancy to 2.1 (SD ± 2.63) at six months postpartum. Maternal and fetal complications were prevalent, with six out of nine pregnancies experiencing adverse outcomes such as false labor, premature rupture of membranes, postpartum hemorrhage, intrauterine growth restriction, preterm birth, stillbirth, and low birth weight. Based on our findings, azathioprine and rituximab may be suitable treatment options for maintaining therapy throughout pregnancy, particularly in cases of high disease activity. Our study highlights the critical need for comprehensive management strategies for NMOSD patients of childbearing age. Preconception planning and counselling, along with early obstetrical consultation and closely monitored treatments during pregnancy and postpartum, are vital to mitigating pregnancy-related relapses and adverse fetal outcomes in this vulnerable patient population.

A roadmap to increasing access to AQP4-Ig testing for NMOSD: expert recommendations

The discovery of aquaporin 4 immunoglobulin G (AQP4-IgG) autoantibody, present in ∼80% of patients with neuromyelitis optica spectrum disorder (NMOSD), dramatically improved its diagnosis, treatment, and prognosis. While Brazil has a higher prevalence of NMOSD (up to 4.5 per 100,000 people) compared with global averages, disparities in access to testing in Brazil impede early diagnosis and treatment. To tackle these issues, the Americas Health Foundation convened a three-day virtual conference with six Brazilian NMOSD experts. This paper emphasizes the importance of addressing the gaps in physicians' knowledge about NMOSD. Stakeholders, including government agencies, should develop national programs for continuing medical education. The public healthcare system should ensure the availability and accessibility of AQP4-IgG antibody testing. Clinical practice guidelines for NMOSD diagnosis and treatment must be established. Such guidelines will enable healthcare providers to manage patients promptly after the initial attack, reducing relapses and improving quality of life. Finally, addressing the fragmented healthcare system, including bridging the gap between public and private institutions and improving access to telemedicine, will aid individuals in Brazil with NMOSD in receiving early diagnosis and treatment. NMOSD presents unique challenges in Brazil because of its higher prevalence and limited access to crucial AQP4-IgG tests. Overcoming these challenges requires collaboration among experts, healthcare providers, government agencies, and the public healthcare system to improve diagnosis, treatment, and patient outcomes.

Small RNA sequencing of differentiated astrocytoma exposed to NMOSD patient sera reveals perturbations in neurodegenerative signaling

The signaling pathways behind severe astrocytic lysis with Aquaporin4 auto-antibody (AQP4-IgG) seropositivity, and reactive astrocytosis with myelin oligodendrocyte glycoprotein auto-antibody (MOG-IgG) seropositivity, remain largely unexplored in Neuromyelitis optica spectrum disorder (NMOSD), while almost no molecular details being known about double-seronegative (DN) patients. Recent discovery of glial fibrillary acidic protein (GFAP) in DN NMOSD patients' cerebrospinal fluid, akin to AQP4-IgG + ve cases, suggests astrocytopathy. Here, we aim to study small non coding RNA (sncRNA) signature alterations in astrocytes exposed to AQP4-IgG + ve and MOG-IgG + ve patient sera, and their potential resemblance with DN-NMOSD. Next Generation Sequencing (NGS) revealed differential expression of several microRNAs with notable alterations in hsa-miR-6824-3p, hsa-miR-324-5p and hsa-miR-4466 respectively upon sera treatment. Results with DN-NMOSD patient sera are majorly similar to that of AQP4+ve sera. Strikingly, in all three treatments, hsa-miR-200b-3p was significantly upregulated. Functional enrichment analysis revealed that Hippo and FoxO signaling pathways were primarily impacted in AQP4-IgG + ve and double negative sera treated cells whereas, MOG-IgG + ve sera treatment perturbed the PI3K-Akt and MAPK signaling pathways. Furthermore, NGS also revealed differential expression of several piRNAs in cells upon treatment with AQP4-IgG + ve and MOG-IgG + ve sera and VEGF signaling was identified as the common target of differentially expressed piRNAs of both the groups. This study, for the first time, revealed that the molecular pathophysiology of double-seronegative NMOSD might involve astrocytopathy akin to AQP4+ve NMOSD, thus pointing towards the possible existence of unidentified astrocytic autoimmune targets and identified the major alterations in intracellular sncRNAs and the associated overall cellular signaling pathways that potentially contribute to the fate of astrocytes during the progression of the disease.

Distinct clinical patterns in AQP4-IgG- positive NMOSD patients vs. Seronegative: Insights from a single-center study in Argentina

BACKGROUND

Distinct clinical course patterns have been identified between AQP4-IgG-positive and AQP4-IgG-negative NMOSD patients.

OBJECTIVES

This study aimed to evaluate the differences between AQP4-IgG-seropositive and AQP4-IgG-seronegative NMOSD patients in a single centre in Argentina.

METHODS

We performed a retrospective cross-sectional study of 108 NMOSD patients in the city of Buenos Aires, Argentina.

RESULTS

We selected 94 for analysis. 77 patients (82 %) were AQP4-IgG positive. In the AQP4-IgG positive group, the ratio of male to female was 1:10 vs. 1:1.2 in the seronegative group (p = 0.001). Relapses were observed in 76 out of 77 (99 %) AQP4-IgG positive patients versus 3 out of 17 (17.6 %) AQP4-IgG negative patients (p = 0.01). In the seropositive group, other autoimmune diseases were present in 34/77 patients (44 %) vs. 2/12 (12 %) in the seronegative patients, a statistically significant difference (p = 0.009). 81 % of the seropositive group had an early adulthood onset (EAO-NMOSD) compared to 35 % in the seronegative group. All AQP4+ patients positive received treatment with monoclonal antibodies. In AQP4-IgG- NMOSD patients the use of immunosuppressive treatment was more common.

CONCLUSION

Female predominance, EAO-NMOSD, recurrence course and a high prevalence of autoimmune disease in AQP4-IgG-positive patients demonstrated a more pronounced autoimmunity profile.

"Lupus Myelitis" Revisited: A Retrospective Single-Center Study of Myelitis Associated With Rheumatologic Disease

BACKGROUND AND OBJECTIVES

Previous reports of patients with myelitis associated with rheumatologic disease may have had unrecognized aquaporin-4 (AQP4)-IgG seropositive neuromyelitis optica spectrum disorder (NMOSD) or myelin oligodendrocyte glycoprotein (MOG)-IgG-associated disease (MOGAD). We clinicoradiologically and serologically characterized patients with myelitis associated with rheumatologic disease evaluated in the era of availability of MOG-IgG and more sensitive AQP4-IgG cell-based assays.

METHODS

A retrospective cohort (2018-2023) at Johns Hopkins Medicine with diagnoses of myelopathy and rheumatologic comorbidity was identified by electronic medical record (EMR) query. All patients with myelitis unrelated to typical multiple sclerosis (MS) were included and analyzed by chart review.

RESULTS

Of 238 patients identified by EMR query, 197 were excluded (148 not meeting prespecified inclusion criteria, 49 had typical MS), resulting in 41 patients for review. The mean age at myelitis onset was 44 ± 15 years; 39 (95%) were female. Rheumatologic diagnoses included 17 (41.5%) with systemic lupus erythematosus (SLE), 10 (24.3%) Sjögren syndrome (SS), 6 (15%) undifferentiated connective tissue disease (UCTD), 5 (12%) combinations of SLE/SS/UCTD with antiphospholipid antibody syndrome, 1 (2.4%) rheumatoid arthritis, 1 (2.4%) psoriatic arthritis, and 1 (2.4%) Behçet disease. 20 patients (49%) were diagnosed with AQP4-IgG seropositive NMOSD, 3 (7%) with MOGAD, and 18 (44%) had "double-seronegative" myelitis. Of these 18, 3 were diagnosed with AQP4-IgG seronegative NMOSD, 1 neuro-Behçet disease, and 14 other (unclassifiable) myelitis. Excluding 1 patient with neuro-Behçet disease, 18 (90%) of 20 AQP4-IgG seropositive patients had longitudinally extensive cord lesions compared with 5 (29%; p < 0.001) of 17 "double-seronegative" patients and 2 (67%) of 3 with MOGAD. "Double-seronegative" patients more commonly had CSF-restricted oligoclonal bands. Functional outcomes did not differ by diagnosis, and most patients received acute immunotherapy at the time of initial myelitis diagnosis with at least partial recovery over a median follow-up of 38 (interquartile range: 9-74) months.

DISCUSSION

Approximately half of our rheumatologic disease cohort with myelitis unrelated to MS had AQP4-IgG seropositive NMOSD while MOGAD accounted for a small but clinically relevant proportion of patients. Further research is needed to characterize myelitis etiology in patients who are seronegative for both AQP4-IgG and MOG-IgG.

Usage status of biologics for the chronic treatment of optic neuritis in neuromyelitis optica spectrum disorders in Japan

PURPOSE

To investigate the usage status of biologics for the chronic treatment of optic neuritis including neuromyelitis optica spectrum disorders in Japan.

DESIGN

Multicenter retrospective case series.

METHODS

Patients diagnosed with anti-aquaporin 4 antibody (AQP4-Ab) positive optic neuritis and had been initiated on biologics (satralizumab, eculizumab, and inebilizumab) between January 2020 and August 2022 were identified at 30 facilities in Japan. These patients were investigated regarding changes in oral steroid doses, optic neuritis relapse, and adverse events after initiation of biologics.

RESULTS

Eighty-eight patients with AQP4-Ab positive optic neuritis initiated on biologics were included. Satralizumab was the most common biologic used (79 patients), followed by eculizumab (6 patients) and inebilizumab (3 patients). In the satralizumab group, during the observation period (10.0±7.0 months) until February 2023, the oral steroid dose was reduced significantly from 13.8 ± 8.6 mg/day at the time of initiation to 5.3 ± 4.8 mg/day (p < 0.001). No relapse of optic neuritis was observed in 76 of 79 patients (96.2%) after initiation of satralizumab. Furthermore, in 15 patients who succeeded in discontinuing steroids during 8.5 ± 5.8 months after initiation of satralizumab, no relapse of optic neuritis was observed throughout the observation period. Adverse events occurred in 7 patients with satralizumab and 2 patients with eculizumab, but no serious infections were observed.

CONCLUSIONS

Satralizumab was the most commonly used biologic for AQP4-Ab positive optic neuritis in Japan. This study demonstrates the efficacy and safety of satralizumab in preventing the relapse of optic neuritis.

Current and Future Roles of Chimeric Antigen Receptor T-Cell Therapy in Neurology: A Review

Importance

Advancements in molecular engineering have facilitated the creation of engineered T cells that express synthetic receptors, termed chimeric antigen receptors (CARs). This is promising not only in cancer treatment but also in addressing a spectrum of other conditions. This review provides a comprehensive overview of the current approaches and future potential of CAR T-cell therapy in the field of neurology, particularly for primary brain tumors and autoimmune neurological disorders.

Observations

CAR T-cell therapy for glioblastoma is promising; however, first-in-human trials did not yield significant success or showed only limited success in a subset of patients. To date, the efficacy of CAR T-cell therapies has been demonstrated in animal models of multiple sclerosis, but larger human studies to corroborate the efficacy remain pending. CAR T cells showed efficacy in treatment of patients with relapsed or refractory aquaporin 4-immunoglobulin G-seropositive neuromyelitis optica spectrum disorders. Further studies with larger patient populations are needed to confirm these results. Success was reported also for treatment of cases with generalized myasthenia gravis using CAR T cells. Chimeric autoantibody receptor T cells, representing a modified form of CAR T cells directed against autoreactive B cells secreting autoantibodies, were used to selectively target autoreactive anti-N-methyl-d-aspartate B cells under in vitro and in vivo conditions, providing the basis for human studies and application to other types of autoimmune encephalitis associated with neuronal or glial antibodies.

Conclusions and Relevance

CAR T cells herald a new era in the therapeutic landscape of neurological disorders. While their application in solid tumors, such as glioblastoma, has not universally yielded robust success, emerging innovative strategies show promise, and there is optimism for their effectiveness in certain autoimmune neurological disorders.

Astrocytes and microglia in multiple sclerosis and neuromyelitis optica

Multiple sclerosis and neuromyelitis optica are autoimmune neurodegenerative diseases primarily targeting myelin sheath and neuroglia. In multiple sclerosis, autoantibodies destroy oligodendrocytes and myelin, which underlies primary neurologic symptoms. Focal damage to myelin triggers reactive astrogliosis and microgliosis, which contribute to and to a large extent define the disease progression. In neuromyelitis optica, autoantibodies against water channel aquaporin 4 (AQP4), which are localized at astrocytic endfeet mediate damage of the glia limitans thus facilitating infiltration of blood-borne molecules and cells that propagate the damage to nerves and neurons. This primary astrocytopathy recruits microglia, which contribute to the neuroinflammatory response. Neuroglial cells therefore are potential targets for cell-specific therapies.

Hyperreflective retinal foci are associated with retinal degeneration after optic neuritis in neuromyelitis optica spectrum disorders and multiple sclerosis

BACKGROUND

Hyperreflective retinal foci (HRF) visualized by optical coherence tomography (OCT) potentially represent clusters of microglia. We compared HRF frequencies and their association with retinal neurodegeneration between people with clinically isolated syndrome (pwCIS), multiple sclerosis (pwMS), aquaporin 4-IgG positive neuromyelitis optica spectrum disorder (pwNMOSD), and healthy controls (HC)-as well as between eyes with (ON+eyes) and without a history of optic neuritis (ON-eyes).

METHODS

Cross-sectional data of pwCIS, pwMS, and pwNMOSD with previous ON and HC were acquired at Charité-Universitätsmedizin Berlin. HRF analysis was performed manually on the central macular OCT scan. Semi-manual OCT segmentation was performed to acquire the combined ganglion cell and inner plexiform layer (GCIPL), inner nuclear layer (INL), and peripapillary retinal nerve fiber layer (pRNFL) thickness. Group comparisons were performed by linear mixed models.

RESULTS

In total, 227 eyes from 88 patients (21 pwCIS, 32 pwMS, and 35 pwNMOSD) and 35 HCs were included. HRF in GCIPL and INL were more frequently detected in pwCIS, pwMS, and pwNMOSD than HCs (p < 0.001 for all comparisons) with pwCIS exhibiting the greatest numbers. ON+eyes of pwMS had less HRF in GCIPL than ON-eyes (p = 0.036), but no difference was seen in pwCIS and pwNMOSD. HRF GCIPL were correlated to GCIPL thickness in ON+eyes in pwMS (p = 0.040) and pwNMOSD (p = 0.031).

CONCLUSION

HRF occur in ON+eyes and ON-eyes across neuroinflammatory diseases. In pwMS and pwNMOSD, HRF frequency was positively associated with GCIPL thickness indicating that HRF formation might be dependent on retinal ganglion cells.

Clinical efficacy of efgartigimod combined with intravenous methylprednisolone in the acute phase of neuromyelitis optica spectrum disorders

BACKGROUND

Neuromyelitis Optica Spectrum Disorders (NMOSD) comprise a group of autoimmune-mediated, inflammatory, demyelinating central nervous system diseases caused by aquaporin-4 (AQP4) IgG autoantibodies. Efgartigimod is a human IgG Fc fragment that reduces antibody titers by targeting the neonatal Fc receptor (FcRn). This study documents the efficacy of efgartigimod combined with intravenous methylprednisolone (IVMP) in the acute phase of NMOSD.

METHODS

In this retrospective study, the medical records of NMOSD patients with acute attack who received efgartigimod plus IVMP or IVMP were reviewed. Treatment efficacy was assessed by the Expanded Disability Scale Score (EDSS) before and one month after treatment. Any side effects that occurred during the treatment period were recorded.

RESULTS

This study was performed on 11 patients (efgartigimod plus IVMP group [n = 4] and IVMP group [n = 7]). Efgartigimod plus IVMP was effective and had a satisfactory safety profile. EDSS was reduced by 0.5 ± 0.32 compared with the IVMP group (0.27 ± 0.02). Immunoglobulin was decreased in three patients, and the immunoglobulin G (IgG) levels gradually increased approximately 8 weeks after the last administration. Hyperlipidemia and elevated white blood cell count were common side effects. No infections or deaths occurred.

CONCLUSIONS

Efgartigimod plus IVMP treatment is safe and well-tolerated in patients with acute-phase NMOSD.

Pediatric Neuroimaging of Multiple Sclerosis and Neuroinflammatory Diseases

Using a pediatric-focused lens, this review article briefly summarizes the presentation of several demyelinating and neuroinflammatory diseases using conventional magnetic resonance imaging (MRI) sequences, such as T1-weighted with and without an exogenous gadolinium-based contrast agent, T2-weighted, and fluid-attenuated inversion recovery (FLAIR). These conventional sequences exploit the intrinsic properties of tissue to provide a distinct signal contrast that is useful for evaluating disease features and monitoring treatment responses in patients by characterizing lesion involvement in the central nervous system and tracking temporal features with blood-brain barrier disruption. Illustrative examples are presented for pediatric-onset multiple sclerosis and neuroinflammatory diseases. This work also highlights findings from advanced MRI techniques, often infrequently employed due to the challenges involved in acquisition, post-processing, and interpretation, and identifies the need for future studies to extract the unique information, such as alterations in neurochemistry, disruptions of structural organization, or atypical functional connectivity, that may be relevant for the diagnosis and management of disease.

Disease characteristics of NMOSD and their relationship with disease burden: Observations from a large single-center cohort

OBJECTIVE

To assess the demographic, clinical, and outcome data in patients with NMOSD across a single-center adult cohort and find out associations, if any, with the disease burden.

BACKGROUND

Neuromyelitis Optica spectrum disorder is an autoimmune condition with unpredictable course and relapses. The clinical and economic burden of NMOSD has been studied less.

DESIGN/METHODS

A retrospective analysis of patients diagnosed with NMOSD according to 2015 criteria at the UT Health Houston (UTH) system from 2010 to 2024 was done.

RESULTS

Of the 68 patients, aged 40.03 yrs. (SD = 14.05), 56 (82.35 %) were females, and 17 (25.75 %) had a median household income below 2 times the poverty threshold. 51 (76.11 %) had positive aquaporin4 antibodies, 39 had optic neuritis (57.35 %), and 29 (42.63 %) had myelitis. We classified total relapses into less than 3 vs more than 3, cumulative days of hospitalization into less than 5 vs more than 5, and readmission frequency as less than 1 vs more than 1 per year. The majority of cases had less than 3 relapses (SN = 38 vs 11, MN = 22 vs 6, p > .05), less than 5 days of cumulative hospitalizations (SN = 29 vs 6, MN = 15 vs 5, p > .05), and less than 1 readmissions in a year (SN 15 vs 5, p > .05, MN = 14 vs 10, p > .05).

CONCLUSION

The severity of the disease can be attributed to the major clinical criteria at the time of diagnosis. This can be helpful to identify cases that may have a higher disease burden to the patient and the hospital. Larger studies are needed to confirm the same.

Neuromyelitis optica spectrum disorder after post appendectomy peritonitis: A case report

Neuromyelitis optica spectrum disorder (NMOSD), also known as "Devic's syndrome", is an autoimmune demyelination disorder. It affects the optic nerve and spinal cord, causing optic neuritis and transverse myelitis. It is associated with anti-aquaporin 4 antibodies that target the aquaporin channel on astrocytes. An 18-year-old male with a history of appendectomy 6 months ago presented with neck pain, numbness in limbs up to the umbilicus, paresis, and spasticity in the left leg. The brain magnetic resonance imaging (MRI) was normal, while the spinal cord MRI showed hyperintense foci at the T2 level. Cerebrospinal fluid (CSF) analysis was in the normal range and negative for oligoclonal bands. The serological assay was positive for anti-aquaporin-4 antibodies (AQP4-IgG). The patient improved significantly after administering high doses of methylprednisolone and supplements. Due to the unavailability of eculizumab, he underwent plasmapheresis sessions to remove antibodies, which improved to a reasonable extent. NMOSD most commonly targets older females, but in our report, it appeared in a young male. The patient only presented with transverse myelitis with no ophthalmologic problem. He made significant improvement with combination treatment of steroids, supplements, and plasmapheresis.

Aberrant hippocampal intrinsic morphological connectivity patterns in Neuromyelitis optica spectrum disorder with cognitive impairment: Insights from an individual-based morphological brain network

BACKGROUND

Although several clinical studies have demonstrated that hippocampus volume loss in neuromyelitis optica spectrum disorder (NMOSD) may be a significant predictor of cognition, no consensus has been reached. To investigate the alterations of the intrinsic ,hippocampal morphological networks in cognitively impaired NMOSD patients and their correlations with cognitive performance.

METHODS

38 NMOSD patients and 39 healthy controls (HC) were enrolled. NMOSD patients were categorized into two groups based on neuropsychological assessment, including the cognitively impaired (CI) group (n = 21) and the cognitively preserved (CP) group (n = 17). Brain high-resolution 3D-T1WI MR images were evaluated, and individual-based intrinsic hippocampus morphological networks were constructed. The between-group differences in global and nodal network topology profiles were estimated, and correlations between the nodal network metrics and cognitive scores were further analyzed.

RESULTS

Compared to the HC and CP groups, the CI group shows significant differences in nodal network metrics of the left hippocampal tail and left hippocampal cornu ammonis (CA) 1-body. Nodal network metrics of the left hippocampal tail were significantly correlated with neurocognitive scores across the entire NMOSD group.

CONCLUSIONS

NMOSD patients with cognitive impairment exhibit abnormal intrinsic hippocampal morphological networks. Nodal network property measurements can help identify those with cognitive impairment.

Biomarkers for neuromyelitis optica: a visual analysis of emerging research trends

Neuromyelitis optica is an inflammatory demyelinating disease of the central nervous system that differs from multiple sclerosis. Over the past 20 years, the search for biomarkers for neuromyelitis optica has been ongoing. Here, we used a bibliometric approach to analyze the main research focus in the field of biomarkers for neuromyelitis optica. Research in this area is consistently increasing, with China and the United States leading the way on the number of studies conducted. The Mayo Clinic is a highly reputable institution in the United States, and was identified as the most authoritative institution in this field. Furthermore, Professor Wingerchuk from the Mayo Clinic was the most authoritative expert in this field. Keyword analysis revealed that the terms "neuromyelitis optica" (261 times), "multiple sclerosis" (220 times), "neuromyelitis optica spectrum disorder" (132 times), "aquaporin 4" (99 times), and "optical neuritis" (87 times) were the most frequently used keywords in literature related to this field. Comprehensive analysis of the classical literature showed that the majority of publications provide conclusive research evidence supporting the use of aquaporin-4-IgG and neuromyelitis optica-IgG to effectively diagnose and differentiate neuromyelitis optica from multiple sclerosis. Furthermore, aquaporin-4-IgG has emerged as a highly specific diagnostic biomarker for neuromyelitis optica spectrum disorder. Myelin oligodendrocyte glycoprotein-IgG is a diagnostic biomarker for myelin oligodendrocyte glycoprotein antibody-associated disease. Recent biomarkers for neuromyelitis optica include cerebrospinal fluid immunological biomarkers such as glial fibrillary acidic protein, serum astrocyte damage biomarkers like FAM19A5, serum albumin, and gamma-aminobutyric acid. The latest prospective clinical trials are exploring the potential of these biomarkers. Preliminary results indicate that glial fibrillary acidic protein is emerging as a promising candidate biomarker for neuromyelitis optica spectrum disorder. The ultimate goal of future research is to identify non-invasive biomarkers with high sensitivity, specificity, and safety for the accurate diagnosis of neuromyelitis optica.

Preceding hepatitis B virus infection is highly prevalent in patients with neuromyelitis optica spectrum disorder in Taiwan

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune inflammatory disease of the central nervous system, characterized by pathogenic anti-Aquaporin-4 antibodies (AQP4-Ab). Given that infections can trigger autoimmune responses, we investigated the association between Hepatitis B virus (HBV) infection and NMOSD.

METHODS

HBV and hepatitis C virus serologies were analyzed in 105 NMOSD patients, 85 multiple sclerosis (MS) patients, and 1,661 healthy Taiwanese controls. Participants were classified into four HBV infection statuses (acute, chronic, resolved, and never infected), and further grouped by vaccination status. Logistic regression was used to estimate odds ratios (OR) for NMOSD development in individuals with chronic or resolved HBV infection.

RESULTS

Among those born before the Taiwan's universal vaccination program, 63.4 % of NMOSD patients had resolved HBV infection, compared to 30.6 % of MS patients and 16.4 % of controls. Resolved HBV infection was associated with a 2.3-fold increased risk for NMOSD development (95 % CI, 1.4-3.8), but not with MS risk. In the post-vaccination cohort, resolved HBV infection remained more frequent in NMOSD patients (8.7 %) than in MS (0 %) and controls (1.8 %). NMOSD patients with resolved HBV infection had later disease onset by 14.6 years and higher Expanded Disability Status Scale (EDSS) scores compared to those without HBV infection, even after adjusting for age and sex (3.5 ± 1.9 vs. 2.2 ± 1.8, p < 0.001).

CONCLUSION

Preceding HBV infection is prevalent among Taiwanese NMOSD patients and is associated with increased disease risk, older age at onset, and greater disability. Screening for HBV is essential for NMOSD patients, particularly in endemic regions.

The Involvement of Glial Cells in Blood-Brain Barrier Damage in Neuroimmune Diseases

The blood-brain barrier and glial cells, particularly astrocytes, interact with each other in neuroimmune diseases. In the inflammatory environment typical of these diseases, alterations in vascular endothelial cell surface molecules and weakened cell connections allow immune cells and autoantibodies to enter the central nervous system. Glial cells influence the adhesion of endothelial cells by changing their morphology and releasing various signaling molecules. Multiple sclerosis has been the most studied disease in relation to vascular endothelial and glial cell interactions, but these cells also significantly affect the onset and severity of other neuroimmune conditions, including demyelinating and inflammatory diseases. In this context, we present an overview of these interactions and highlight how they vary across different neuroimmune diseases.

Eculizumab Use in Neuromyelitis Optica Spectrum Disorders: Routine Clinical Care Data From a European Cohort

BACKGROUND AND OBJECTIVES

Attack prevention is crucial in managing neuromyelitis optica spectrum disorders (NMOSDs). Eculizumab (ECU), an inhibitor of the terminal complement cascade, was highly effective in preventing attacks in a phase III trial of aquaporin-4 (AQP4)-IgG seropositive(+) NMOSDs. In this article, we evaluated effectiveness and safety of ECU in routine clinical care.

METHODS

We retrospectively evaluated patients with AQP4-IgG+ NMOSD treated with ECU between December 2014 and April 2022 at 20 German and 1 Austrian university center(s) of the Neuromyelitis Optica Study Group (NEMOS) by chart review. Primary outcomes were effectiveness (assessed using annualized attack rate [AAR], MRI activity, and disability changes [Expanded Disability Status Scale {EDSS}]) and safety (including adverse events, mortality, and attacks after meningococcal vaccinations), analyzed by descriptive statistics.

RESULTS

Fifty-two patients (87% female, age 55.0 ± 16.3 years) received ECU for 16.2 (interquartile range [IQR] 9.6 - 21.7) months. Forty-five patients (87%) received meningococcal vaccination before starting ECU, 9 with concomitant oral prednisone and 36 without. Seven of the latter (19%) experienced attacks shortly after vaccination (median: 9 days, IQR 6-10 days). No postvaccinal attack occurred in the 9 patients vaccinated while on oral prednisone before starting ECU and in 25 (re-)vaccinated while on ECU. During ECU therapy, 88% of patients were attack-free. The median AAR decreased from 1.0 (range 0-4) in the 2 years preceding ECU to 0 (range 0-0.8; p < 0.001). The EDSS score from start to the last follow-up was stable (median 6.0), and the proportion of patients with new T2-enhancing or gadolinium-enhancing MRI lesions in the brain and spinal cord decreased. Seven patients (13%) experienced serious infections. Five patients (10%; median age 53.7 years) died on ECU treatment (1 from myocardial infarction, 1 from ileus with secondary sepsis, and 3 from systemic infection, including 1 meningococcal sepsis), 4 were older than 60 years and severely disabled at ECU treatment start (EDSS score ≥ 7). The overall discontinuation rate was 19%.

DISCUSSION

Eculizumab proved to be effective in preventing NMOSD attacks. An increased risk of attacks after meningococcal vaccination before ECU start and potentially fatal systemic infections during ECU-particularly in patients with comorbidities-must be considered. Further research is necessary to explore optimal timing for meningococcal vaccinations.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that eculizumab reduces annualized attack rates and new MRI lesions in AQP4-IgG+ patients with NMOSD.

Effects of early intervention in neuromyelitis optica spectrum disorder patients with seropositive AQP4 antibodies

Background

The impact of early intervention with immunosuppressive treatment (IST) in anti-Aquaporin4-antibody (AQP4-ab) seropositive neuromyelitis optica spectrum disorder (NMOSD) has not been thoroughly evaluated.

Objective

This study aims to assess the effects of early IST intervention in patients with NMOSD.

Methods

This retrospective cohort study included 174 treatments from 137 NMOSD patients seropositive for AQP4-antibody, treated with ISTs such as rituximab, mycophenolate mofetil, azathioprine, or tacrolimus. Multiple statistical analyses, including regression discontinuity design (RDD), kaplan-meier analyze, Cox proportional hazards regression model, were employed to evaluate the effects of early IST intervention on annualized relapse rate (ARR) change, Expanded Disability Status Scale (EDSS) change, and time to next relapse.

Results

A total of 174 treatments from 137 patients were analyzed. Patients exhibited significant improvement in ARR[1.95 vs.0, IQR (0.70-6.0 vs. 0-0.42), p<0.001] and EDSS [3.0 vs. 2.5, IQR (2.0-4.0 vs. 1.0-3.0) p<0.001]after IST, although the ARR change was not significant in patients treated with TAC. Early IST initiation was associated with greater improvements in both ARR and EDSS compared to later initiation. RDD analysis demonstrated a time-dependent effect of ARR-change, indicating greater efficacy with early IST intervention.

Conclusions

Early intervention with ISTs in AQP4-antibody-positive NMOSD patients is associated with better outcomes in terms of reducing relapse rate and improving disability. These findings underscore the importance of early treatment in NMOSD.

The prevalence, incidence, and clinical assessment of neuromyelitis optica spectrum disorder in patients with demyelinating diseases

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is characterised by recurrent attacks of optic neuritis and transverse myelitis. The purpose of this work was to identify the incidence and prevalence of NMOSD and its clinical characteristics in the population treated for demyelinating diseases in Western Mexico.

MATERIAL AND METHOD

A descriptive, retrospective study was carried out in the Department of Neurology, at the Sub-specialty Medical Unit, Specialties Hospital (known by its Spanish abbreviation UMAE-HE), of the National Western Medical Center (CMNO), Mexican Institute of Social Security (IMSS). A review of the electronic files for all patients with a diagnosis of NMOSD in 2019, was carried out in the State of Jalisco, Mexico.

RESULTS

Fifty-eight patients with NMOSD were included in the study. The incidence was 0.71/100 000 (CI 0.60-0.85) and the prevalence was 1.09/100 000 (CI 0.84-1.42). There were 79.3% women, and 20.6% were men (P = .01). All (100%) patients presented with anti-aquaporin-4 immunoglobulin G, and 89.6% showed seropositivity for anti-aquaporin-4 (CI 82.6-94.9). Magnetic resonance imaging was performed on 100% of patients, where 34.4% were normal, and 65.5% (38) abnormal, presenting with non-specific subcortical lesions (P = 0.04). The initial clinical presentation was optic neuritis (ON) in 58.6%; where 31.0% was bilateral ON, 20.7% was left ON, and 6.9% were right ON; transverse myelitis in 26.0%, area postrema syndrome (APS) in 10.3%, among others.

CONCLUSIONS

The incidence of NMOSD exceeds 0.71/100 000, the prevalence is low at 1.09/100 000, and NMOSD is predominantly found in women.

An evaluation of ravulizumab for the treatment of neuromyelitis optica spectrum disorder

INTRODUCTION

Following the CHAMPION-NMOSD trial, the FDA recently granted approval for ravulizumab, a humanized monoclonal antibody against complement C5 protein in AQP-4 seropositive neuromyelitis optica spectrum disorder (NMOSD). Similar to eculizumab, ravulizumab offers near-complete prevention of NMOSD relapses, but has a longer half-life, providing decreased infusion frequency and increased convenience for patients. While targeting the complement pathway has clear advantages, patients are at risk for infection with encapsulated organisms, in particular Neisseria meningitidis.

AREAS COVERED

In this paper, we discuss the details of the CHAMPION-NMOSD trial and discuss challenges in meningitis prevention and strategies for switching therapies.

EXPERT OPINION

Ravulizumab improves on eculizumab's success as a highly effective NMOSD therapy by decreasing infusion frequency, thereby increasing patient convenience. We predict that ravulizumab will eventually replace eculizumab but may not have a similar impact on inebelizumab or satralizumab. Patients taking C5 complement inhibitors have an increased risk of serious meningococcal infections, such as invasive meningococcal disease (IMD), and have incomplete protection against IMD despite immunization. Thus, we recommend that in addition to standard pre-immunizations against Neisseria meningitidis, patients should also be assessed for starting on appropriate antibiotic prophylaxis against IMD, based on local resistance patterns.

Artificial intelligence in healthcare: a mastery

There is a vast development of artificial intelligence (AI) in recent years. Computational technology, digitized data collection and enormous advancement in this field have allowed AI applications to penetrate the core human area of specialization. In this review article, we describe current progress achieved in the AI field highlighting constraints on smooth development in the field of medical AI sector, with discussion of its implementation in healthcare from a commercial, regulatory and sociological standpoint. Utilizing sizable multidimensional biological datasets that contain individual heterogeneity in genomes, functionality and milieu, precision medicine strives to create and optimize approaches for diagnosis, treatment methods and assessment. With the arise of complexity and expansion of data in the health-care industry, AI can be applied more frequently. The main application categories include indications for diagnosis and therapy, patient involvement and commitment and administrative tasks. There has recently been a sharp rise in interest in medical AI applications due to developments in AI software and technology, particularly in deep learning algorithms and in artificial neural network (ANN). In this overview, we enlisted the major categories of issues that AI systems are ideally equipped to resolve followed by clinical diagnostic tasks. It also includes a discussion of the future potential of AI, particularly for risk prediction in complex diseases, and the difficulties, constraints and biases that must be meticulously addressed for the effective delivery of AI in the health-care sector.

Aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder triggered by herpes zoster: a case report and literature review

This paper presents the case of a 45-year-old woman who developed aquaporin-4 (AQP4) antibody-positive neuromyelitis optica spectrum disorder (NMOSD) approximately 6 weeks after a herpes zoster infection. Her initial symptoms included area postrema syndrome, which was marked by persistent nausea, vomiting, and belching. This report also provides a summary of the demographic and clinical features, disease progression, magnetic resonance imaging findings, cerebrospinal fluid analysis, treatment plans, and recovery outcomes of 11 patients-including this case and 10 others reported in the literature since 2008-who developed AQP4 antibody-positive NMOSD following herpes zoster infection. This review aims to improve clinicians' understanding of the characteristics, treatment, and prognosis of this disease. It also highlights the importance for pain management specialists to consider central pain and use the MIDNIGHTS or VINDψCATE mnemonic devices to systematically consider the differential diagnoses of a patient's new pain symptoms.