1
|
Hacohen Y. Pediatric Autoimmune Neurologic Disorders. Continuum (Minneap Minn) 2024; 30:1160-1188. [PMID: 39088292 DOI: 10.1212/con.0000000000001464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE This article discusses common principles in diagnosing and managing autoimmune neurologic conditions in children. LATEST DEVELOPMENTS The key to improving outcomes in all patients with autoimmune neurologic diseases is making an early diagnosis, promptly initiating treatment, and identifying patients who will benefit from long-term maintenance treatment. Some neuroinflammatory syndromes can be diagnosed with an antibody biomarker (eg, aquaporin-4 antibodies, N-methyl-d-aspartate [NMDA] receptor antibodies), whereas others require clinical diagnostic criteria (eg, multiple sclerosis, opsoclonus-myoclonus syndrome). A proportion of children will be labeled as seronegative, and further investigations for other inflammatory or monogenetic etiologies need to be carried out in parallel with treating the central nervous system inflammation. Time to treatment and treatment escalation were shown to correlate with outcomes in many patients with these disorders. The choice and duration of treatment should be evaluated considering side effects and risks in the short and long terms. The presence of a highly inflammatory disease process in children supports the use of highly effective disease-modifying therapies in pediatrics. ESSENTIAL POINTS The phenotypes of pediatric autoimmune neurologic conditions may change across different age groups, as the brain is still actively developing. In general, the presentation in children is more inflammatory, but overall disability is lower, likely because of better neuroplasticity and repair. Convincing evidence has increasingly emerged to support the biological rationale that effective immunosuppressive therapies used in adult neuroimmunology are equally effective in children.
Collapse
|
2
|
Carnero Contentti E, Lopez PA, Patrucco L, Cristiano E, Miguez J, Silva B, Liwacki S, Tkachuk V, Balbuena ME, Vrech C, Deri N, Correale J, Marrodan M, Ysrraelit MC, Fiol M, Leguizamon F, Luetic G, Tavolini D, Mainella C, Zanga G, Burgos M, Hryb J, Barboza A, Lazaro L, Alonso R, Fernández Liguori N, Nadur D, Martinez A, Steinberg J, Carrá A, Alonso Serena M, Rojas JI. Traditional first-line treatment failure rates in neuromyelitis optica spectrum disorder patients included in the Argentinean registry (RelevarEM). Mult Scler Relat Disord 2024; 89:105771. [PMID: 39033591 DOI: 10.1016/j.msard.2024.105771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/29/2024] [Accepted: 07/14/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Immunosuppressive therapies as azathioprine (AZA), mycophenolate mofetil (MMF) and rituximab (RTX) are widely prescribed as first-line treatment to prevent relapses in NMOSD. However, the rate of response to these traditional therapies is unknown in Argentina. We aimed to describe and compare treatment failure rates in NMOSD patients included in the Argentinean MS and NMOSD registry (RelevarEM, NCT03375177). METHODS A retrospective cohort study was conducted in NMOSD patients included in RelevarEM (a nationwide, longitudinal, observational, non-mandatory registry of MS and NMOSD in Argentina). NMOSD patients were defined based on validate diagnostic criteria. Only NMOSD patients who received AZA or MMF for at least 6 months or RTX for at least 1 month were included. Patients who were receiving AZA, MMF, or RTX and then switched to another 1 of these 3 therapies were included if the above-mentioned criteria for each drug were fulfilled. Data on patient demographics, clinical, neuroradiological findings, and treatments administered were collected. Treatment failure was defined as any new attack/relapse that occurred despite immunosuppressive treatment. RESULTS We included 139 NMOSD patients who were receiving AZA (n = 105), MMF (n = 5) or RTX (n = 29) with a mean follow-up time of 41.3 ± 11.4 months and median of EDSS at treatment initiation of 3. We observed a reduction in the annualized relapse rate from pre-treatment to post-treatment of 51.1 %, 48.4 %, and 79.1 % respectively with a Hazard Risk relative to RTX (95 % CI) of 1.67 (1.34-3.54, p = 0.01) for AZA and 2.01 (1.86-4.43, p = 0.008) for MMF. AZA, MMF and RTX failure was observed in 45/105 (42.8 %), 2/5 (40 %) and 3/29 (10.3 %) patients, respectively. CONCLUSIONS Treatment failure rates were higher for AZA and MMF than RTX in Argentinean NMOSD patients in a real-world setting. High-efficacy treatment increases the opportunity to prevent attacks of NMOSD.
Collapse
Affiliation(s)
- Edgar Carnero Contentti
- Neuroimmunology Unit, Department of Neurosciences, Hospital Aleman, Buenos Aires, Argentina.
| | - Pablo A Lopez
- Neuroimmunology Unit, Department of Neurosciences, Hospital Aleman, Buenos Aires, Argentina
| | - Liliana Patrucco
- Centro Esclerosis Múltiple Buenos Aires (CEMBA)Buenos Aires, Argentina
| | - Edgardo Cristiano
- Centro Esclerosis Múltiple Buenos Aires (CEMBA)Buenos Aires, Argentina
| | - Jimena Miguez
- Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Berenice Silva
- Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Neurology Department, Hospital JM Ramos Mejia, Buenos Aires, Argentina
| | - Susana Liwacki
- Neurology Unit, Hospital Córdoba, Córdoba, Argentina; Clínica Universitaria Reina Fabiola, Córdoba, Argentina
| | - Verónica Tkachuk
- Neuroimmunology Unit, Neurology Department, Hospital de Clínicas, Buenos Aires, Argentina
| | - María E Balbuena
- Neuroimmunology Unit, Neurology Department, Hospital de Clínicas, Buenos Aires, Argentina
| | - Carlos Vrech
- Neurology Department, Sanatorio Allende, Córdoba, Argentina
| | - Norma Deri
- CENyR, Ciudad de Buenos Aires, Buenos Aires, Argentina
| | | | | | | | - Marcela Fiol
- Neurology Department, Fleni, Buenos Aires, Argentina
| | - Felisa Leguizamon
- Neurology Department, Hospital de Agudos Dr. Teodoro Álvarez, Buenos Aires, Argentina
| | - Geraldine Luetic
- Neurology Department, Instituto de Neurocienciencias, Rosario, Argentina
| | - Darío Tavolini
- Neurology Department, INECO Neurociencias Oroño, Santa Fe, Argentina
| | - Carolina Mainella
- Neurology Department, Hospital Español de Rosario, Santa Fe, Argentina
| | - Gisela Zanga
- Neurology Department, Unidad Asistencial César Milstein, Buenos Aires, Argentina
| | - Marcos Burgos
- Neurology Department, Hospital San Bernardo, Salta, Argentina
| | - Javier Hryb
- Neurology Department, Hospital de Agudos Dr. Carlos G. Durand, Buenos Aires, Argentina
| | - Andrés Barboza
- Neurology Department, Hospital Central de Mendoza, Mendoza, Argentina
| | - Luciana Lazaro
- Neurology Department, Sanatorio Guemes, Buenos Aires, Argentina
| | - Ricardo Alonso
- Neurology Department, Hospital JM Ramos Mejia, Buenos Aires, Argentina; Neurology Department, Sanatorio Guemes, Buenos Aires, Argentina
| | | | - Débora Nadur
- Neuroimmunology Unit, Neurology Department, Hospital de Clínicas, Buenos Aires, Argentina
| | - Alejandra Martinez
- Neurology Department, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Judith Steinberg
- Neurology Department, Private office, Lujan, Buenos Aires, Argentina
| | - Adriana Carrá
- Neurology Department, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Marina Alonso Serena
- Neurology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan I Rojas
- Centro Esclerosis Múltiple Buenos Aires (CEMBA)Buenos Aires, Argentina
| |
Collapse
|
3
|
Carnero Contentti E, Lopez PA, Pettinicchi JP, Miguez J, Patrucco L, Cristiano E, Liwacki S, Tkachuk V, Balbuena ME, Vrech C, Deri N, Correale J, Marrodan M, Ysrraelit MC, Leguizamon F, Luetic G, Tavolini D, Mainella C, Zanga G, Burgos M, Hryb J, Barboza A, Lazaro L, Alonso R, Fernández Liguori N, Nadur D, Alonso Serena M, Caride A, Rojas JI. Treatment strategies and responses for attacks of neuromyelitis optica spectrum disorder: A real-world retrospective cohort study. J Neurol Sci 2024; 462:123099. [PMID: 38897155 DOI: 10.1016/j.jns.2024.123099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 06/21/2024]
Abstract
We aimed to assess the treatment strategies utilized in patients with neuromyelitis optica spectrum disorder (NMOSD) experiencing relapses, including their frequency, types, and response after 6 months based on the Expanded Disability Status Scale (EDSS) score. METHODS We conducted a retrospective study involving NMOSD patients from the Argentinean MS and NMOSD registry (RelevarEM, NCT03375177). Treatment response at 6 months was categorized as "good" if the EDSS score decreased by ≥1 point after a nadir EDSS score ≤ 3, or by ≥2 points after a nadir EDSS score > 3, "poor" if the EDSS score decrease was slighter, and as "absent" if the EDSS score remained unchanged or worsened. RESULTS We included 120 NMOSD patients (seropositive N = 75), who experienced 250 NMOSD-related relapses and received 248 treatments. At 6 months, complete recovery was achieved in 70/98 (71.4%) and 15/19 (79%) patients, respectively. Predictors of a "good" response in our regression model were a younger age at disease onset (OR:3.54, CI95% 2.45-5.01, p < 0.0001) and a short delay from onset of relapse to treatment initiation (OR:1.56, CI95% 1.22-2.13, p = 0.004). CONCLUSIONS Approximately two-thirds of patients experienced complete recovery, and younger age and a short delay to start treatment were independent predictors of a "good" response.
Collapse
Affiliation(s)
- Edgar Carnero Contentti
- Neuroimmunology Unit, Department of Neurosciences, Hospital Alemán, Buenos Aires, Argentina.
| | - Pablo A Lopez
- Neuroimmunology Unit, Department of Neurosciences, Hospital Alemán, Buenos Aires, Argentina
| | - Juan Pablo Pettinicchi
- Neuroimmunology Unit, Department of Neurosciences, Hospital Alemán, Buenos Aires, Argentina
| | - Jimena Miguez
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Liliana Patrucco
- Centro de esclerosis múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Edgardo Cristiano
- Centro de esclerosis múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Susana Liwacki
- Clínica Universitaria Reina Fabiola, Córdoba, Argentina; Servicio de Neurología - Hospital Córdoba, Córdoba
| | - Verónica Tkachuk
- Sección de Neuroinmunología y Enfermedades Desmielinizantes, Servicio de Neurología - Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - María E Balbuena
- Sección de Neuroinmunología y Enfermedades Desmielinizantes, Servicio de Neurología - Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Carlos Vrech
- Departamento de Enfermedades desmielinizantes - Sanatorio Allende, Córdoba, Argentina
| | | | - Jorge Correale
- Departamento de Neurología - FLENI, Buenos Aires, Argentina
| | | | | | | | | | | | | | - Gisela Zanga
- Unidad asistencial César Milstein, Buenos Aires, Argentina
| | - Marcos Burgos
- Servicio de Neurología - Hospital San Bernardo, Salta, Argentina
| | - Javier Hryb
- Servicio de Neurología - Hospital Carlos G. Durand, Buenos Aires, Argentina
| | | | | | | | | | - Débora Nadur
- Sección de Neuroinmunología y Enfermedades Desmielinizantes, Servicio de Neurología - Hospital de Clínicas José de San Martín, Buenos Aires, Argentina; Hospital Naval, Buenos Aires, Argentina
| | - Marina Alonso Serena
- Servicio de clínica médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Alejandro Caride
- Neuroimmunology Unit, Department of Neurosciences, Hospital Alemán, Buenos Aires, Argentina
| | - Juan I Rojas
- Centro de esclerosis múltiple de Buenos Aires, Buenos Aires, Argentina; Servicio de Neurología, Hospital Universitario de CEMIC, Buenos Aires, Argentina
| |
Collapse
|
4
|
Wassmer E, Billaud C, Absoud M, Abdel-Mannan O, Benetou C, Cummins C, Forrest K, De Goede C, Eltantawi N, Hickson H, Hussain N, Jardine P, Livingston JH, Mordekar S, Ramdas S, Taylor M, Vijayakumar K, West S, Whitehouse WP, Kneen R, Hemingway C, Lim M, Hacohen Y, Wright S. Long term outcome in non-multiple sclerosis paediatric acquired demyelinating syndromes. Eur J Paediatr Neurol 2024; 52:52-58. [PMID: 39025036 DOI: 10.1016/j.ejpn.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 06/03/2024] [Accepted: 07/02/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVES We aimed to study the risks of relapse and long term disability in children with non-MS acquired demyelinating syndromes (ADS). METHODS In this prospective, multi-centre study, from the 14 UK pediatric neurology centres, children (<16 years) experiencing a first episode of ADS were recruited from 2010 to 2014. Case report forms were collected prospectively. RESULTS A total of 269 children were recruited and followed up for a median of 7.2 years. Median age at onset was 9y (IQR 9.5-14.5, 126 females). At last follow-up, 46 (18 %) had MS, 4 AQP4-Ab NMOSD and 206 (80 %) had other ADS, of which 27 (13 %) relapsed. Relapsing MOGAD was the diagnosis in 12/27, 6 were seronegative and 9 did not have antibodies tested. Frequency of relapse differed according to first presentation in non-MS ADS, being least likely in transverse myelitis (p = 0.025). In the non-MS group, MOG-Ab was predictive of relapse (HR = 8.42; p < 0.001) occurring 8 times as often decreasing over time. Long-term difficulties did not differ between children with monophasic vs relapsing diseases. CONCLUSION The risk of relapse in non-MS ADS depends on initial diagnosis, and MOG-Ab positivity. Long-term difficulties are observed regardless of relapses and are determined by presenting phenotype.
Collapse
Affiliation(s)
- Evangeline Wassmer
- Birmingham Children's Hospital, Birmingham, UK; Institute of Health and Neurodevelopment, Aston University, Birmingham, UK.
| | - Charly Billaud
- Institute of Health and Neurodevelopment, Aston University, Birmingham, UK
| | | | - Omar Abdel-Mannan
- Great Ormond Street Hospital, London, UK; Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, London, UK
| | | | | | - Katharine Forrest
- University Hospital Southampton, Southampton, UK; Royal Hospital for Children, Glasgow, UK
| | | | - Noha Eltantawi
- Birmingham Children's Hospital, Birmingham, UK; Manoura University, Egypt
| | - Helga Hickson
- Birmingham Children's Hospital, Birmingham, UK; Maidston and Tunbridge Wells, UK
| | | | - Phil Jardine
- University Hospital Bristol NHS Foundation Trust, Bristol, UK
| | | | | | | | | | - K Vijayakumar
- University Hospital Bristol NHS Foundation Trust, Bristol, UK; Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - William P Whitehouse
- Nottingham University Hospitals, Nottingham, UK; University of Nottingham, Nottingham, UK
| | | | | | - Ming Lim
- Evelina London Children's Hospital, London, UK; Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Yael Hacohen
- Great Ormond Street Hospital, London, UK; Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, London, UK
| | - Sukhvir Wright
- Birmingham Children's Hospital, Birmingham, UK; Institute of Health and Neurodevelopment, Aston University, Birmingham, UK
| |
Collapse
|
5
|
Wang G, Chen X, Wang X, Duan Y, Gao H, Ji X, Zhu Y, Xiang X, Ma H, Li Y, Xue Q. Abnormal brain spontaneous neural activity in neuromyelitis optica spectrum disorder with neuropathic pain. Front Neurol 2024; 15:1408759. [PMID: 38938780 PMCID: PMC11210278 DOI: 10.3389/fneur.2024.1408759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/30/2024] [Indexed: 06/29/2024] Open
Abstract
Background Neuropathic pain is one of the most common symptoms in neuromyelitis optica spectrum disorder (NMOSD). Notwithstanding, its underlying mechanism remains obscure. Methods The amplitude of low-frequency fluctuations (ALFF) metric was employed to investigate spontaneous neural activity alterations via resting-state functional magnetic resonance imaging (rs-MRI) data from a 3.0 T MRI scanner, in a sample of 26 patients diagnosed with NMOSD with neuropathic pain (NMOSD-WNP), 20 patients with NMOSD but without neuropathic pain (NMOSD-WoNP), and 38 healthy control (HC) subjects matched for age and sex without the comorbidity of depressive or anxious symptoms. Results It was observed that patients with NMOSD-WNP displayed a significant ALFF decrease in the left amygdala and right anterior insula, relative to both patients with NMOSD-WoNP and HC subjects. Furthermore, ALFF values in the left amygdala were negatively correlated with the scores of the Douleur Neuropathique en 4 Questions and McGill Pain Questionnaire (both sensory and affective descriptors) in patients with NMOSD-WNP. Additionally, there were negative correlations between the ALFF values in the right anterior insula and the duration of pain and the number of relapses in patients with NMOSD-WNP. Conclusion The present study characterizes spontaneous neural activity changes in brain regions associated with sensory and affective processing of pain and its modulation, which underscore the central aspects in patients with NMOSD-WNP. These findings might contribute to a better understanding of the pathophysiologic basis of neuropathic pain in NMOSD.
Collapse
Affiliation(s)
- Gendi Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Neurology, Yancheng Third People’s Hospital, Yancheng, China
| | - Xiang Chen
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoyuan Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yinghui Duan
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hanqing Gao
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaopei Ji
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yunfei Zhu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xuanyi Xiang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hairong Ma
- Department of Neurology, Kunshan Hospital of Chinese Medicine, Suzhou, China
| | - Yonggang Li
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Medical Imaging, Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qun Xue
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Clinical Immunology, Jiangsu Institute of Clinical Immunology, The First Affiliated Hospital of Soochow University, Suzhou, China
| |
Collapse
|
6
|
Chen H, Xu Z, Zhou Y, Jiang YH, Chen J, Xiong Y, Zhou M, Wu X, Hong D. Rituximab-induced gut microbiota changes in Chinese neuromyelitis optica spectrum disorders. Mult Scler Relat Disord 2024; 86:105606. [PMID: 38636269 DOI: 10.1016/j.msard.2024.105606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/30/2024] [Accepted: 04/07/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Recent evidence shows that immunosuppressive agents can affect the gut microbiota in autoimmune diseases. However, the relationship between the gut microbiome and B-cell depletion immunotherapy in neuromyelitis optica spectrum disorder (NMOSD) remains poorly understood. OBJECTIVES To evaluate the distinct intestinal microbial patterns and serum cytokine levels after short-term rituximab treatment (three months) in patients with NMOSD. METHODS Firstly, we conducted a cross-sectional study involving 46 treatment-naïve NMOSD patients and 48 matched healthy controls. We collected fecal specimens, which were then analyzed using next-generation sequencing, and quantified serum cytokines. Subsequently, fecal and serum samples were re-collected and re-evaluated in 31 of the 46 treatment-naïve NMOSD patients after RTX treatment. RESULTS Comparing the gut microbiome of treatment-naïve NMOSD patients to that of healthy controls revealed low α-diversity and distinct microbial compositions in the former. The microbial composition in NMOSD patients underwent changes following three months of RTX treatment. Specifically, the levels of IL-17F and IL-6 decreased, while those of IL-10 and TNFα increased after RTX treatment. LEfSe analysis identified 27 KEGG categories with significantly differential abundances between NMOSD patients and RTX treatment group. CONCLUSIONS Our study provides a comprehensive understanding of the gut microbiota landscape in the context of B-cell depletion immunotherapy. We observed dysbiosis in the gut microbiome of NMOSD patients, which was partially alleviated by three months of RTX treatment. This suggests that B-cell depletion may play a crucial role in driving changes in the gastrointestinal environment.
Collapse
Affiliation(s)
- Hao Chen
- Department of Neurology, The First Affiliated Hospital Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Zubing Xu
- Department of Neurology, The First Affiliated Hospital Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Yu Zhou
- Department of Neurology, The First Affiliated Hospital Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Yu-Huan Jiang
- Medical Laborotary, The First Affiliated Hospital Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Jin Chen
- Department of Neurology, The First Affiliated Hospital Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Yingqiong Xiong
- Department of Neurology, The First Affiliated Hospital Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Meihong Zhou
- Department of Neurology, The First Affiliated Hospital Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Xiaomu Wu
- Department of Neurology, The First Affiliated Hospital Nanchang University, Nanchang, Jiangxi Province, 330006, China.
| | - Daojun Hong
- Department of Neurology, The First Affiliated Hospital Nanchang University, Nanchang, Jiangxi Province, 330006, China.
| |
Collapse
|
7
|
Clardy SL, Pittock SJ, Aktas O, Nakahara J, Isobe N, Centonze D, Fam S, Kielhorn A, Yu JC, Jansen J, Zhang I. Network Meta-analysis of Ravulizumab and Alternative Interventions for the Treatment of Neuromyelitis Optica Spectrum Disorder. Neurol Ther 2024; 13:535-549. [PMID: 38722571 PMCID: PMC11136926 DOI: 10.1007/s40120-024-00597-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/23/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Anti-aquaporin-4 antibody-positive (AQP4-Ab+) neuromyelitis optica spectrum disorder (NMOSD) is a complement-mediated autoimmune disease in which unpredictable and relapsing attacks on the central nervous system cause irreversible and accumulating damage. Comparative efficacy of new NMOSD therapies, such as ravulizumab, with established therapies is critical in making informed treatment decisions. METHODS Efficacy of ravulizumab relative to established AQP4-Ab+ NMOSD treatments, such as eculizumab, inebilizumab, and satralizumab, was evaluated in a Bayesian network meta-analysis (NMA). Data were extracted from trials identified by a systematic literature review. The final evidence base consisted of 17 publications representing five unique and global studies (PREVENT, N-MOmentum, SAkuraSky, SAkuraStar, and CHAMPION-NMOSD). The primary endpoint was time-to-first relapse; other outcomes included annualized relapse rates (ARRs). RESULTS For patients receiving monotherapy (monoclonal antibody only), ravulizumab was associated with a lower risk of relapse than inebilizumab (hazard ratio [HR] 0.09, 95% credible interval [CrI] 0.02, 0.57) or satralizumab (HR 0.08, 95% CrI 0.01, 0.55) and was comparable to eculizumab (HR 0.86, 95% Crl 0.16, 4.52). Ravulizumab + immunosuppressive therapy (IST) was associated with a lower risk of relapse than satralizumab + IST (HR 0.15, 95% CrI 0.03, 0.78); the comparison with eculizumab + IST suggested no difference. No patients treated with inebilizumab received background IST and were thus excluded from analysis. The ARR with ravulizumab monotherapy was 98% lower compared with inebilizumab (rate ratio [RR] 0.02, 95% Crl 0.00, 0.38) and satralizumab (RR 0.02, 95% Crl 0.00, 0.42) monotherapies. The ARR with ravulizumab ± IST showed the strongest treatment-effect estimates compared with other interventions. CONCLUSION In the absence of head-to-head randomized controlled trials, NMA results suggest ravulizumab, a C5 inhibitor, is likely to be more effective in preventing NMOSD relapse in patients with AQP4-Ab+ NMOSD when compared with other treatments having different methods of action.
Collapse
Affiliation(s)
- Stacey L Clardy
- Department of Neurology, University of Utah, 175 Medical Drive North, Salt Lake City, UT, 84132, USA.
| | | | - Orhan Aktas
- Heinrich Heine University, Dusseldorf, Germany
| | - Jin Nakahara
- Keio University School of Medicine, Tokyo, Japan
| | | | - Diego Centonze
- Tor Vergata University, Rome, Italy
- IRCCS Neuromed, Pozzilli, Italy
| | - Sami Fam
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | | | - Jeffrey C Yu
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | | | | |
Collapse
|
8
|
Jacob S. Treating myasthenia gravis beyond the eye clinic. Eye (Lond) 2024:10.1038/s41433-024-03133-x. [PMID: 38789789 DOI: 10.1038/s41433-024-03133-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/17/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Myasthenia gravis (MG) is one of the most well characterised autoimmune disorders affecting the neuromuscular junction with autoantibodies targeting the acetylcholine receptor (AChR) complex. The vast majority of patients present with ocular symptoms including double vision and ptosis, but may progress on to develop generalised fatiguable muscle weakness. Severe involvement of the bulbar muscles can lead to dysphagia, dysarthria and breathing difficulties which can progress to myasthenic crisis needing ventilatory support. Given the predominant ocular onset of the disease, it is important that ophthalmologists are aware of the differential diagnosis, investigations and management including evolving therapies. When the disease remains localised to the extraocular muscles (ocular MG) IgG1 and IgG3 antibodies against the AChR (including clustered AChR) are present in nearly 50% of patients. In generalised MG this is seen in nearly 90% patients. Other antibodies include those against muscle specific tyrosine kinase (MuSK) and lipoprotein receptor related protein 4 (LRP4). Even though decremental response on repetitive nerve stimulation is the most well recognised neurophysiological abnormality, single fibre electromyogram (SFEMG) in experienced hands is the most sensitive test which helps in the diagnosis. Initial treatment should be using cholinesterase inhibitors and then proceeding to immunosuppression using corticosteroids and steroid sparing drugs. Patients requiring bulbar muscle support may need rescue therapies including plasma exchange and intravenous immunoglobulin (IVIg). Newer therapeutic targets include those against the B lymphocytes, complement system, neonatal Fc receptors (FcRn) and various other elements of the immune system.
Collapse
Affiliation(s)
- Saiju Jacob
- University Hospitals Birmingham, Birmingham, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
| |
Collapse
|
9
|
Gupta M, Khandelwal NK, Nelson A, Hwang P, Pourmal S, Bennett JL, Stroud RM. Structural Basis of Aquaporin-4 Autoantibody Binding in Neuromyelitis Optica. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.12.592631. [PMID: 38798537 PMCID: PMC11118524 DOI: 10.1101/2024.05.12.592631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Neuromyelitis Optica (NMO) is an autoimmune disease of the central nervous system where pathogenic autoantibodies target the human astrocyte water channel aquaporin-4 causing neurological impairment. Autoantibody binding leads to complement dependent and complement independent cytotoxicity, ultimately resulting in astrocyte death, demyelination, and neuronal loss. Aquaporin-4 assembles in astrocyte plasma membranes as symmetric tetramers or as arrays of tetramers. We report molecular structures of aquaporin-4 alone and bound to Fab fragments from patient-derived NMO autoantibodies using cryogenic electron microscopy. Each antibody binds to epitopes comprised of three extracellular loops of aquaporin-4 with contributions from multiple molecules in the assembly. The structures distinguish between antibodies that bind to the tetrameric form of aquaporin-4, and those targeting higher order orthogonal arrays of tetramers that provide more diverse bridging epitopes.
Collapse
Affiliation(s)
- Meghna Gupta
- Department of Biochemistry and Biophysics, University of California San Francisco; San Francisco, CA 94143, USA
- current address: Department of Chemical Physiology and Biochemistry, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Nitesh Kumar Khandelwal
- Department of Biochemistry and Biophysics, University of California San Francisco; San Francisco, CA 94143, USA
| | - Andrew Nelson
- Department of Biochemistry and Biophysics, University of California San Francisco; San Francisco, CA 94143, USA
| | - Peter Hwang
- Department of Biochemistry and Biophysics, University of California San Francisco; San Francisco, CA 94143, USA
| | - Sergei Pourmal
- Department of Biochemistry and Biophysics, University of California San Francisco; San Francisco, CA 94143, USA
| | - Jeffrey L. Bennett
- Departments of Neurology and Ophthalmology, Programs in Neuroscience and Immunology, University of Colorado School of Medicine, Anschutz Medical Campus; Aurora, CO 80045, USA
| | - Robert M. Stroud
- Department of Biochemistry and Biophysics, University of California San Francisco; San Francisco, CA 94143, USA
| |
Collapse
|
10
|
Saballegue JCD, Tiongson MLGP. Rituximab Therapy for Double Seronegative Neuromyelitis Optica Spectrum Disease. Cureus 2024; 16:e60004. [PMID: 38854188 PMCID: PMC11162507 DOI: 10.7759/cureus.60004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2024] [Indexed: 06/11/2024] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare central nervous system disease presenting as optic neuritis, myelitis, and brainstem syndromes. It may be aquaporin-4 seropositive, anti-myelin oligodendrocyte glycoprotein (MOG) antibody seropositive, or double seronegative. Double-seronegative NMOSD can pose a diagnostic and therapeutic challenge. Treatment typically aims to decrease the incidence of relapse, for which high-dose intravenous methylprednisolone is the first-line agent. Non-steroid treatments include azathioprine, mycophenolate mofetil, and rituximab. This case describes a 45-year-old female presenting with left arm numbness and weakness for three months. She had been previously diagnosed with optic neuritis in 2013 but was lost to follow-up. Progression of weakness warranted admission to the neurology department. Diagnostic work and imaging were suggestive of neuromyelitis optica. Tests for aquaporin-4, anti-MOG, immunoglobulin G, and immunoglobulin M in the cerebrospinal fluid were all negative. Initial treatment comprised methylprednisolone; however, due to the progression of symptoms, she was given two cycles of rituximab. Rituximab targets the CD20 antigen in B cells and is thought to reduce the risk of relapse and the severity of NMOSD. The patient's Barthel index score, expanded disability status scale score, and motor examination improved after two cycles of rituximab.
Collapse
|
11
|
Cobo-Calvo Á, Gómez-Ballesteros R, Orviz A, Díaz Sánchez M, Boyero S, Aguado-Valcarcel M, Sepúlveda M, Rebollo P, López-Laiz P, Maurino J, Téllez Lara N. Therapeutic inertia in the management of neuromyelitis optica spectrum disorder. Front Neurol 2024; 15:1341473. [PMID: 38450077 PMCID: PMC10915282 DOI: 10.3389/fneur.2024.1341473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/02/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction and objective Limited information is available on how neurologists make therapeutic decisions in neuromyelitis optica spectrum disorder (NMOSD), especially when new treatments with different mechanisms of action, administration, and safety profile are being approved. Decision-making can be complex under this uncertainty and may lead to therapeutic inertia (TI), which refers to lack of treatment initiation or intensification when therapeutic goals are not met. The study aim was to assess neurologists' TI in NMOSD. Methods An online, cross-sectional study was conducted in collaboration with the Spanish Society of Neurology. Neurologists answered a survey composed of demographic characteristics, professional background, and behavioral traits. TI was defined as the lack of initiation or intensification with high-efficacy treatments when there is evidence of disease activity and was assessed through five NMOSD aquaporin-4 positive (AQP4+) simulated case scenarios. A multivariate logistic regression analysis was used to determine the association between neurologists' characteristics and TI. Results A total of 78 neurologists were included (median interquartile range [IQR] age: 36.0 [29.0-46.0] years, 55.1% male, median [IQR] experience managing demyelinating conditions was 5.2 [3.0-11.1] years). The majority of participants were general neurologists (59.0%) attending a median (IQR) of 5.0 NMOSD patients (3.0-12.0) annually. Thirty participants (38.5%) were classified as having TI. Working in a low complexity hospital and giving high importance to patient's tolerability/safety when choosing a treatment were predictors of TI. Conclusion TI is a common phenomenon among neurologists managing NMOSD AQP4+. Identifying TI and implementing specific intervention strategies may be critical to improving therapeutic decisions and patient care.
Collapse
Affiliation(s)
- Álvaro Cobo-Calvo
- Centre d’Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Aida Orviz
- Department of Neurology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - María Díaz Sánchez
- Department of Neurology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Sabas Boyero
- Department of Neurology, Hospital Universitario Cruces, Bilbao, Spain
| | | | - María Sepúlveda
- Department of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | | | | | - Nieves Téllez Lara
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| |
Collapse
|
12
|
Gao Y, Cai L, Wu Y, Jiang M, Zhang Y, Ren W, Song Y, Li L, Lei Z, Wu Y, Zhu L, Li J, Li D, Li G, Luo C, Tao L. Emerging functions and therapeutic targets of IL-38 in central nervous system diseases. CNS Neurosci Ther 2024; 30:e14550. [PMID: 38334236 PMCID: PMC10853902 DOI: 10.1111/cns.14550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/08/2023] [Accepted: 11/20/2023] [Indexed: 02/10/2024] Open
Abstract
Interleukin (IL)-38 is a newly discovered cytokine of the IL-1 family, which binds various receptors (i.e., IL-36R, IL-1 receptor accessory protein-like 1, and IL-1R1) in the central nervous system (CNS). The hallmark physiological function of IL-38 is competitive binding to IL-36R, as does the IL-36R antagonist. Emerging research has shown that IL-38 is abnormally expressed in the serum and brain tissue of patients with ischemic stroke (IS) and autism spectrum disorder (ASD), suggesting that IL-38 may play an important role in neurological diseases. Important advances include that IL-38 alleviates neuromyelitis optica disorder (NMOD) by inhibiting Th17 expression, improves IS by protecting against atherosclerosis via regulating immune cells and inflammation, and reduces IL-1β and CXCL8 release through inhibiting human microglial activity post-ASD. In contrast, IL-38 mRNA is markedly increased and is mainly expressed in phagocytes in spinal cord injury (SCI). IL-38 ablation attenuated SCI by reducing immune cell infiltration. However, the effect and underlying mechanism of IL-38 in CNS diseases remain inadequately characterized. In this review, we summarize the biological characteristics, pathophysiological role, and potential mechanisms of IL-38 in CNS diseases (e.g., NMOD, Alzheimer's disease, ASD, IS, TBI, and SCI), aiming to explore the therapeutic potential of IL-38 in the prevention and treatment of CNS diseases.
Collapse
Affiliation(s)
- Yuan Gao
- Department of Forensic Medicine, School of Basic Medicine and Biological SciencesSoochow UniversitySuzhouChina
- Department of NeurosurgeryPennsylvania State University College of MedicineState CollegePennsylvaniaUSA
- Department of Forensic ScienceWenzhou Medical UniversityWenzhouZhejiangChina
| | - Luwei Cai
- Department of Forensic Medicine, School of Basic Medicine and Biological SciencesSoochow UniversitySuzhouChina
| | - Yulu Wu
- Department of Forensic Medicine, School of Basic Medicine and Biological SciencesSoochow UniversitySuzhouChina
| | - Min Jiang
- Department of Forensic Medicine, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yidan Zhang
- Department of Forensic Medicine, School of Basic Medicine and Biological SciencesSoochow UniversitySuzhouChina
| | - Wenjing Ren
- Department of Forensic Medicine, School of Basic Medicine and Biological SciencesSoochow UniversitySuzhouChina
| | - Yirui Song
- Department of Forensic Medicine, School of Basic Medicine and Biological SciencesSoochow UniversitySuzhouChina
| | - Lili Li
- Department of Child and Adolescent HealthcareChildren's Hospital of Soochow UniversitySuzhouChina
| | - Ziguang Lei
- Department of Forensic ScienceWenzhou Medical UniversityWenzhouZhejiangChina
| | - Youzhuang Wu
- Department of Forensic ScienceWenzhou Medical UniversityWenzhouZhejiangChina
| | - Luwen Zhu
- Department of Forensic ScienceWenzhou Medical UniversityWenzhouZhejiangChina
| | - Jing Li
- Department of Forensic Medicine, School of Basic Medicine and Biological SciencesSoochow UniversitySuzhouChina
| | - Dongya Li
- Department of OrthopedicsThe Affiliated Hospital of Xuzhou Medical UniversityXuzhouChina
| | - Guohong Li
- Department of NeurosurgeryPennsylvania State University College of MedicineState CollegePennsylvaniaUSA
| | - Chengliang Luo
- Department of Forensic Medicine, School of Basic Medicine and Biological SciencesSoochow UniversitySuzhouChina
| | - Luyang Tao
- Department of Forensic Medicine, School of Basic Medicine and Biological SciencesSoochow UniversitySuzhouChina
| |
Collapse
|
13
|
Levy M. Immune-Mediated Myelopathies. Continuum (Minneap Minn) 2024; 30:180-198. [PMID: 38330478 PMCID: PMC10868882 DOI: 10.1212/con.0000000000001382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Immune-mediated myelopathies are conditions in which the immune system attacks the spinal cord. This article describes the distinguishing characteristics of immune-mediated myelopathies and treatment strategies for patients affected by these disorders. LATEST DEVELOPMENTS New biomarkers, such as aquaporin 4 and myelin oligodendrocyte glycoprotein antibodies, in the blood and spinal fluid have led to the identification of antigen-specific immune-mediated myelopathies and approved therapies to prevent disease progression. ESSENTIAL POINTS The first step in the diagnosis of an immune-mediated myelopathy is confirming that the immune system is the cause of the attack by excluding non-immune-mediated causes. The second step is to narrow the differential diagnosis based on objective biomarkers such as serology and MRI patterns. The third step is to treat the specific immune-mediated myelopathy by using evidence-based medicine.
Collapse
|
14
|
Carnero Contentti E, Wingerchuk DM. MRI of the relevant domain should be performed to confirm whether clinical symptoms represent an attack of NMOSD: Yes. Mult Scler 2024; 30:19-21. [PMID: 38197556 DOI: 10.1177/13524585231222132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
|
15
|
Jin TY, Lin BT, Dai LJ, Lu X, Gao H, Hu J. Anti-glial fibrillary acidic protein antibody and anti-aquaporin-4 antibody double-positive neuromyelitis optica spectrum disorder: A case report. World J Clin Cases 2023; 11:8192-8199. [PMID: 38130792 PMCID: PMC10731168 DOI: 10.12998/wjcc.v11.i34.8192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/20/2023] [Accepted: 11/29/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND A case of neuromyelitis optica spectrum disorder (NMOSD) with positive cerebrospinal fluid (CSF) anti-aquaporin-4 antibody (AQP4-IgG) and anti-glial fibrillary acidic protein IgG (GFAP-IgG) at the time of relapse was reported. The exact roles of GFAP-IgG in NMOSD are not fully understood and are the subject of ongoing research. This study revealed the possible connection between GFAP-IgG and the occurrence or development of diseases. CASE SUMMARY A 19-year-old woman was admitted to the hospital due to a constellation of symptoms, including dizziness, nausea, and vomiting that commenced 1 year prior, reoccurred 2 mo ago, and were accompanied by visual blurring that also began 2 mo ago. Additionally, she presented with slurred speech and ptosis, both of which emerged 1 mo ago. Notably, her symptoms deteriorated 10 d prior to admission, leading to the onset of arm and leg weakness. During hospitalization, magnetic resonance imaging showed high T2-fluid attenuated inversion recovery signals, and slightly high and equal diffusion-weighted imaging signals. The serum antibody of AQP4-IgG tested positive at a dilution of 1:100. CSF antibody testing showed positive results for GFAP-IgG at a dilution of 1:10 and AQP4-IgG at a dilution of 1:32. Based on these findings, the patient was diagnosed with NMOSD. She received intravenous methylprednisolone at a daily dose of 500 mg for 5 d, followed by a tapering-off period. Afterward, the rate of reduction was gradually slowed down and the timely use of immunosuppressants was implemented. CONCLUSION The CFS was slightly GFAP-IgG-positive during the relapse period, which can aid in the diagnosis and treatment of the disease.
Collapse
Affiliation(s)
- Ting-Yu Jin
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Bing-Tong Lin
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Li-Jv Dai
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Xia Lu
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Han Gao
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Jin Hu
- Department of Neurology, First Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| |
Collapse
|
16
|
Kraker JA, Chen JJ. An update on optic neuritis. J Neurol 2023; 270:5113-5126. [PMID: 37542657 DOI: 10.1007/s00415-023-11920-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 07/27/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
Optic neuritis (ON) is the most common cause of subacute optic neuropathy in young adults. Although most cases of optic neuritis (ON) are classified as typical, meaning idiopathic or associated with multiple sclerosis, there is a growing understanding of atypical forms of optic neuritis such as antibody mediated aquaporin-4 (AQP4)-IgG neuromyelitis optica spectrum disorder (NMOSD) and the recently described entity, myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD). Differentiating typical ON from atypical ON is important because they have different prognoses and treatments. Findings of atypical ON, including severe vision loss with poor recovery with steroids or steroid dependence, prominent optic disc edema, bilateral vision loss, and childhood or late adult onset, should prompt serologic testing for AQP4-IgG and MOG-IgG. Although the traditional division of typical and atypical ON can be helpful, it should be noted that there can be severe presentations of otherwise typical ON and mild presentations of atypical ON that blur these traditional lines. Rare causes of autoimmune optic neuropathies, such as glial fibrillary acidic protein (GFAP) and collapsin response-mediator protein 5 (CRMP5) autoimmunity also should be considered in patients with bilateral painless optic neuropathy associated with optic disc edema, especially if there are other accompanying suggestive neurologic symptoms/signs. Typical ON usually recovers well without treatment, though recovery may be expedited by steroids. Atypical ON is usually treated with intravenous steroids, and some forms, such as NMOSD, often require plasma exchange for acute attacks and long-term immunosuppressive therapy to prevent relapses. Since treatment is tailored to the cause of the ON, elucidating the etiology of the ON is of the utmost importance.
Collapse
Affiliation(s)
- Jessica A Kraker
- Department of Ophthalmology, Mayo Clinic Hospital, Rochester, MN, USA
| | - John J Chen
- Department of Ophthalmology, Mayo Clinic Hospital, Rochester, MN, USA.
- Department of Neurology, Mayo Clinic Hospital, Rochester, MN, USA.
| |
Collapse
|
17
|
Park SY, Kwon YN, Kim S, Kim SH, Kim JK, Kim JS, Nam TS, Min YG, Park KS, Park JS, Seok JM, Sung JJ, Sohn E, Shin KJ, Shin JH, Shin HY, Oh SI, Oh J, Yoon BA, Lee S, Lee JM, Lee HL, Choi K, Huh SY, Jang MJ, Min JH, Kim BJ, Kim SM. Early rituximab treatment reduces long-term disability in aquaporin-4 antibody-positive neuromyelitis optica spectrum. J Neurol Neurosurg Psychiatry 2023; 94:800-805. [PMID: 37268404 DOI: 10.1136/jnnp-2022-330714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/12/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorder (NMOSD) causes relapsing inflammatory attacks in the central nervous system, leading to disability. As rituximab, a B-lymphocyte-depleting monoclonal antibody, is an effective in preventing NMOSD relapses, we hypothesised that earlier initiation of rituximab can also reduce long-term disability of patients with NMOSD. METHODS This multicentre retrospective study involving 19 South Korean referral centres included patients with NMOSD with aquaporin-4 antibodies receiving rituximab treatment. Factors associated with the long-term Expanded Disability Status Scale (EDSS) were assessed using multivariable regression analysis. RESULTS In total, 145 patients with rituximab treatment (mean age of onset, 39.5 years; 88.3% female; 98.6% on immunosuppressants/oral steroids before rituximab treatment; mean disease duration of 121 months) were included. Multivariable analysis revealed that the EDSS at the last follow-up was associated with time to rituximab initiation (interval from first symptom onset to initiation of rituximab treatment). EDSS at the last follow-up was also associated with maximum EDSS before rituximab treatment. In subgroup analysis, the time to initiation of rituximab was associated with EDSS at last follow-up in patients aged less than 50 years, female and those with a maximum EDSS score ≥6 before rituximab treatment. CONCLUSIONS Earlier initiation of rituximab treatment may prevent long-term disability worsening in patients with NMOSD, especially among those with early to middle-age onset, female sex and severe attacks.
Collapse
Affiliation(s)
- Su Yeon Park
- Department of Neurology, Korea Cancer Center Hospital, Seoul, Korea (the Republic of)
| | - Young Nam Kwon
- Department of Neurology, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Sunyoung Kim
- Department of Neurology, Ulsan University Hospital College of Medicine, Ulsan, Korea (the Republic of)
| | - Seung-Hyun Kim
- Department of Neurology, Hanyang University College of Medicine, Seoul, Korea (the Republic of)
| | - Jong Kuk Kim
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea (the Republic of)
| | - Jun-Soon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea (the Republic of)
| | - Tai-Seung Nam
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea (the Republic of)
| | - Young Gi Min
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Kyung Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea (the Republic of)
| | - Jin-Sung Park
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea (the Republic of)
| | - Jin Myoung Seok
- Department of Neurology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea (the Republic of)
| | - Jung-Joon Sung
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Eunhee Sohn
- Department of Neurology, Chungnam National University, College of Medicine, Daejeon, Korea (the Republic of)
| | - Kyong Jin Shin
- Department of Neurology, Haeundae Paik Hospital, Inje University, Busan, Korea (the Republic of)
| | - Jin-Hong Shin
- Department of Neurology, Pusan National University Yangsan Hospital, Yangsan, Korea (the Republic of)
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Seong-Il Oh
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea (the Republic of)
| | - Jeeyoung Oh
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea (the Republic of)
| | - Byeol-A Yoon
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea (the Republic of)
| | - Sanggon Lee
- Department of Neurology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea (the Republic of)
| | - Jong-Mok Lee
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea (the Republic of)
| | - Hye Lim Lee
- Department of Neurology, Korea University College of Medicine, Seoul, Korea (the Republic of)
| | - Kyomin Choi
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea (the Republic of)
| | - So-Young Huh
- Department of Neurology, Kosin University College of Medicine, Busan, Korea (the Republic of)
| | - Myoung-Jin Jang
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Ju-Hong Min
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of)
| | - Byoung Joon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of)
| | - Sung-Min Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| |
Collapse
|
18
|
Jiang W, Yin X, Wang Y, Ding Y, Pan Y, Zheng G, Lv H, Chen K, Li S, Wang L, Shi Y, Li G, Zhang G. Establishment of a comprehensive diagnostic model for neuromyelitis optica spectrum disorders based on the analysis of laboratory indicators and clinical data. Neurol Sci 2023; 44:3647-3657. [PMID: 37191810 DOI: 10.1007/s10072-023-06853-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND To establish a comprehensive diagnostic model for neuromyelitis optica spectrum disorders (NMOSDs) based on laboratory indicators and clinical data. METHODS A retrospective method was used to query the medical records of patients with NMOSD from January 2019 to December 2021. At the same time, clinical data of other neurological diseases were also collected for comparison. Clinical data of the NMOSD group and non-NMOSD group were analyzed, and the diagnostic model was established based on these data. In addition, the model was evaluated and verified by the receiver operating curve. RESULTS A total of 73 patients with NMOSD were included, and the ratio of males to females was 1:3.06. The indicators that showed differences between the NMOSD group and non NMOSD group included neutrophils (P = 0.0438), PT (P = 0.0028), APTT (P < 0.0001), CK (P = 0.002), IBIL (P = 0.0181), DBIL (P < 0.0001), TG (P = 0.0078), TC (P = 0.0117), LDL-C (P = 0.0054), ApoA1 (P = 0.0123), ApoB (P = 0.0217), TPO antibody (P = 0.012), T3 (P = 0.0446), B lymphocyte subsets (P = 0.0437), urine sg (P = 0.0123), urine pH (P = 0.0462), anti-SS-A antibody (P = 0.0036), RO-52 (P = 0.0138), CSF simplex virus antibody I-IGG (P = 0.0103), anti-AQP4 antibody (P < 0.0001), and anti-MOG antibody (P = 0.0036). Logistic regression analysis showed that changes in ocular symptoms, anti-SSA antibody, anti-TPO antibody, B lymphocyte subsets, anti-AQP4 antibody, anti-MOG antibody, TG, LDL, ApoB, and APTT had a significant impact on diagnosis. The AUC of the combined analysis was 0.959. The AUC of the new ROC for AQP4- and MOG- antibody negative NMOSD was 0.862. CONCLUSIONS A diagnostic model was successfully established, which can play an important role in differential diagnosis of NMOSD.
Collapse
Affiliation(s)
- Wencan Jiang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
- NMPA Key Laboratory for Quality Control for In Vitro Diagnostic, Beijing, China
| | - Xiaoxuan Yin
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Yufei Wang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Yaowei Ding
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Yu Pan
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Guanghui Zheng
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- NMPA Key Laboratory for Quality Control for In Vitro Diagnostic, Beijing, China
| | - Hong Lv
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Kelin Chen
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Siwen Li
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Lijuan Wang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Yijun Shi
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Guoge Li
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Guojun Zhang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China.
- NMPA Key Laboratory for Quality Control for In Vitro Diagnostic, Beijing, China.
| |
Collapse
|
19
|
Yong HYF, Burton JM. A Clinical Approach to Existing and Emerging Therapeutics in Neuromyelitis Optica Spectrum Disorder. Curr Neurol Neurosci Rep 2023; 23:489-506. [PMID: 37540387 DOI: 10.1007/s11910-023-01287-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE OF REVIEW Neuromyelitis optica spectrum disorder (NMOSD) is a rare but highly disabling disease of the central nervous system. Unlike multiple sclerosis, disability in NMOSD occurs secondary to relapses that, not uncommonly, lead to blindness, paralysis, and death. Recently, newer, targeted immunotherapies have been trialed and are now in the treatment arsenal. We have endeavoured to evaluate the current state of NMOSD therapeutics. RECENT FINDINGS This review provides a pragmatic evaluation of recent clinical trials and post-marketing data for rituximab, inebilizumab, satralizumab, eculizumab, and ravalizumab, contrasted to older agents. We also review contemporary issues such as treatment in the context of SARS-CoV2 infection and pregnancy. There has been a dramatic shift in NMOSD morbidity and mortality with earlier and improved disease recognition, diagnostic accuracy, and the advent of more effective, targeted therapies. Choosing a maintenance therapy remains nuanced depending on patient factors and accessibility. With over 100 putative agents in trials, disease-free survival is now a realistic goal for NMOSD patients.
Collapse
Affiliation(s)
- Heather Y F Yong
- Division of Neurology, Department of Clinical Neurosciences, University of Calgary, Cummings School of Medicine, Calgary, AB, Canada
| | - Jodie M Burton
- Division of Neurology, Department of Clinical Neurosciences, University of Calgary, Cummings School of Medicine, Calgary, AB, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
| |
Collapse
|
20
|
Lazzaro C, Mazzanti NA, Rossi S, Parazzini F. Inebilizumab for neuromyelitis optica spectrum disorders in Italy: a budget impact model. Expert Rev Pharmacoecon Outcomes Res 2023; 23:1185-1200. [PMID: 37795872 DOI: 10.1080/14737167.2023.2267176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/01/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND The Italian National Health Service (INHS) has recently reimbursed the monoclonal antibody inebilizumab as a second line monotherapy after rituximab (RTX) use for neuromyelitis optica spectrum disorders (NMOSD) patients ≥ 18 years anti-aquaporin 4 antibody-immunoglobulin G positive, who experienced a relapse in the last year or cannot receive RTX, if incident patients. Other INHS-reimbursed drugs for NMOSD treatment are satralizumab, eculizumab and, off-label, besides RTX, ocrelizumab, tocilizumab, and immunosuppressants. RESEARCH DESIGN AND METHODS A 3-year (2023-2025) prevalence-based budget impact model following the INHS viewpoint compared the costs and the NMOSD attacks without (1st scenario) and with inebilizumab (2nd scenario). The epidemiology of NMOSD, and the INHS-funded healthcare resources (drugs and their administration; specialist visits; hospitalizations due to drug-related adverse events and NMOSD attacks) were obtained from the literature. One-way, threshold value and scenario sensitivity analyses investigated the robustness of the baseline findings. RESULTS During 2023-2025 inebilizumab saves the INHS €8,373,125.13 (1st scenario: €176,770,028.63; 2nd scenario: €168,396,903.50) and 12.74 NMOSD attacks (1st scenario: 213.94; 2nd scenario: 201.19). Sensitivity analyses confirmed the robustness of the baseline results. CONCLUSION Inebilizumab reduces the INHS expenditure for NMOSD drugs. Future research should explore the cost-effectiveness of inebilizumab vs other NMOSD-targeting drugs in Italy.
Collapse
Affiliation(s)
- Carlo Lazzaro
- Studio di Economia Sanitaria, Milan, Italy
- Biology and Biotechnologies Department "Lazzaro Spallanzani", University of Pavia, Pavia, Italy
| | | | | | - Fabio Parazzini
- Department of Clinical Sciences and Community Health (DISCCO), University of Milan, Milan, Italy
| |
Collapse
|
21
|
Jagannath P, K MS, S SMA, Kulkarni A, Prashanth PSSS, Madan H, Anand A. Neuromyelitis optica spectrum disorder with AQP4-IgG presenting as area postrema syndrome and progressing to myelitis: A rare case report. Clin Case Rep 2023; 11:e7636. [PMID: 37415585 PMCID: PMC10319961 DOI: 10.1002/ccr3.7636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023] Open
Abstract
Key Clinical Message Neuromyelitis optica spectrum disorders can less commonly present with area postrema syndrome progressing to myelitis. Management involves intravenous glucocorticoids, plasma exchange, and preventive immunotherapy. Abstract Neuromyelitis optica spectrum disorders can less commonly present with area postrema syndrome progressing to myelitis. The majority of patients have positive AQP4-Ab. Diagnosis is based on clinical and imaging findings. These patients can be treated with intravenous glucocorticoids, plasma exchange, and preventive immunotherapy.
Collapse
Affiliation(s)
| | - Mohammed Suhail K
- Department of General MedicineM S Ramaiah Medical CollegeBengaluruIndia
| | | | - Ashwin Kulkarni
- Department of General MedicineM S Ramaiah Medical CollegeBengaluruIndia
| | | | - Hritik Madan
- Adesh Medical College and HospitalKurukshetraHaryanaIndia
| | - Ayush Anand
- BP Koirala Institute of Health SciencesDharanNepal
| |
Collapse
|
22
|
Allu SVV, Parikh HR, Schmidt P, Alonso G, Khanal S, Fortuzi K, Khaja M. An Atypical Presentation of Chronic Inflammatory Myelin Degeneration in Neuromyelitis Optica (NMO). Cureus 2023; 15:e41803. [PMID: 37575757 PMCID: PMC10422679 DOI: 10.7759/cureus.41803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/15/2023] Open
Abstract
Neuromyelitis optica (NMO) is an autoimmune disorder characterized by aquaporin-4 (AQP4) IgG autoantibodies. These autoantibodies induce chronic neuroinflammatory damage to the spinal cord and optic nerve. NMO clinically manifests as relapsing and overlapping neurodegenerative episodes of optic neuritis (ON) and transverse myelitis (TM). Contrasting from other autoimmune neurodegenerative disorders, NMO has a poor prognostic profile often involving permanent neurological disability. We present a case of a 65-year-old male who presented with a progressive weakening in his left upper and lower extremities with reduced sensation and was found to have an acute flare of NMO. We explore the broad symptomatology involved in the disorder along with relevant crucial imaging findings pointing toward the diagnosis of NMO. Finally, we discuss treatment modalities in the context of our patient's clinical course and prognostic factors. Early intervention and suppression of relapse in this neuroinflammatory neurodegenerative disorder can help decrease the duration of acute flares and improve long-term outcomes for patients affected by NMO.
Collapse
Affiliation(s)
| | | | | | | | - Sneha Khanal
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Ked Fortuzi
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Misbahuddin Khaja
- Internal Medicine and Pulmonary Critical Care, Icahn School of Medicine at Mount Sinai/BronxCare Health System, Bronx, USA
| |
Collapse
|
23
|
Alkabie S, Casserly CS, Morrow SA, Racosta JM. Identifying specific myelopathy etiologies in the evaluation of suspected myelitis: A retrospective analysis. J Neurol Sci 2023; 450:120677. [PMID: 37207546 DOI: 10.1016/j.jns.2023.120677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/13/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Myelopathies require prompt etiologic diagnosis. We aimed to identify a specific myelopathy diagnosis in cases of suspected myelitis to highlight clinicoradiologic differences. METHODS In this retrospective, single-centre cohort of subjects with suspected myelitis referred to London Multiple Sclerosis (MS) Clinic between 2006 and 2021, we identified those with MS and reviewed the remaining charts for etiologic diagnosis based on clinical, serologic, and imaging details. RESULTS Of 333 included subjects, 318/333 (95.5%) received an etiologic diagnosis. Most (274/333, 82%) had MS or clinically isolated syndrome. Spinal cord infarction (n = 10) was the commonest non-inflammatory myelitis mimic characterized by hyperacute decline (n = 10/10, 100%), antecedent claudication (n = 2/10, 20%), axial owl/snake eye (n = 7/9, 77%) and sagittal pencillike (n = 8/9, 89%) MRI patterns, vertebral artery occlusion/stenosis (n = 4/10, 40%), and concurrent acute cerebral infarct (n = 3/9, 33%). Longitudinal lesions were frequent in aquaporin-4-IgG-positive neuromyelitis optica spectrum disorder (AQP4+NMOSD) (n = 7/7, 100%) and myelin oligodendrocyte glycoprotein-IgG-associated disorder (MOGAD) (n = 6/7, 86%), accompanied by bright spotty (n = 5/7, 71%) and central-grey-restricted (n = 4/7, 57%) T2-lesions on axial sequences, respectively. Leptomeningeal (n = 4/4, 100%), dorsal subpial (n = 4/4, 100%) enhancement, and positive body PET/CT (n = 4/4, 100%) aided the diagnosis of sarcoidosis. Spondylotic myelopathies had chronic sensorimotor presentations (n = 4/6, 67%) with relative bladder sparing (n = 5/6, 83%), localizable to sites of disc herniation (n = 6/6, 100%). Metabolic myelopathies showed dorsal column or inverted 'V' sign (n = 2/3, 67%) MRI T2-abnormality with B12 deficiency. CONCLUSIONS Although no single feature reliably confirms or refutes a specific myelopathy diagnosis, this study highlights patterns that narrow the differential diagnosis of myelitis and facilitate early recognition of mimics.
Collapse
Affiliation(s)
- Samir Alkabie
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Courtney S Casserly
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Sarah A Morrow
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Juan M Racosta
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich Medicine and Dentistry, Western University, London, Ontario, Canada; MS Epidemiology Lab, London, Ontario, Canada.
| |
Collapse
|
24
|
Al-Ani A, Chen JJ, Costello F. Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD): current understanding and challenges. J Neurol 2023:10.1007/s00415-023-11737-8. [PMID: 37154894 PMCID: PMC10165591 DOI: 10.1007/s00415-023-11737-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 05/10/2023]
Abstract
New diagnostic criteria for myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) have recently been proposed, distinguishing this syndrome from other inflammatory diseases of the central nervous system. Seropositivity status for MOG-IgG autoantibodies is important for diagnosing MOGAD, but only in the context of robust clinical characterization and cautious interpretation of neuroimaging. Over the last several years, access to cell-based assay (CBA) techniques has improved diagnostic accuracy, yet the positive predictive value of serum MOG-IgG values varies with the prevalence of MOGAD in any given patient population. For this reason, possible alternative diagnoses need to be considered, and low MOG-IgG titers need to be carefully weighted. In this review, cardinal clinical features of MOGAD are discussed. Key challenges to the current understanding of MOGAD are also highlighted, including uncertainty regarding the specificity and pathogenicity of MOG autoantibodies, the need to identify immunopathologic targets for future therapies, the quest to validate biomarkers that facilitate diagnosis and detect disease activity, and the importance of deciphering which patients with MOGAD require long-term immunotherapy.
Collapse
Affiliation(s)
- Abdullah Al-Ani
- Section of Ophthalmology, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - John J Chen
- Department of Ophthalmology and Neurology, Mayo Clinic, Rochester, MN, USA
| | - Fiona Costello
- Section of Ophthalmology, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
25
|
Nair SS, Jacob S. Novel Immunotherapies for Myasthenia Gravis. Immunotargets Ther 2023; 12:25-45. [PMID: 37038596 PMCID: PMC10082579 DOI: 10.2147/itt.s377056] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/03/2023] [Indexed: 04/07/2023] Open
Abstract
Myasthenia gravis (MG), a prototype autoimmune neurological disease, had its therapy centred on corticosteroids, non-steroidal broad-spectrum immunotherapy and cholinesterase inhibitors for several decades. Treatment-refractory MG and long-term toxicities of the medications have been major concerns with the conventional therapies. Advances in the immunology and pathogenesis of MG have ushered in an era of newer therapies which are more specific and efficacious. Complement inhibitors and neonatal Fc receptor blockers target disease-specific pathogenic mechanisms linked to myasthenia and have proven their efficacy in pivotal clinical studies. B cell-depleting agents, specifically rituximab, have also emerged as useful for the treatment of severe MG. Many more biologicals are in the pipeline and in diverse stages of development. This review discusses the evidence for the novel therapies and the specific issues related to their clinical use.
Collapse
Affiliation(s)
- Sruthi S Nair
- Department of Neurology, University Hospitals Birmingham, Birmingham, B15 2TH, UK
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Saiju Jacob
- Department of Neurology, University Hospitals Birmingham, Birmingham, B15 2TH, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| |
Collapse
|
26
|
Mader S, Ho S, Wong HK, Baier S, Winklmeier S, Riemer C, Rübsamen H, Fernandez IM, Gerhards R, Du C, Chuquisana O, Lünemann JD, Lux A, Nimmerjahn F, Bradl M, Kawakami N, Meinl E. Dissection of complement and Fc-receptor-mediated pathomechanisms of autoantibodies to myelin oligodendrocyte glycoprotein. Proc Natl Acad Sci U S A 2023; 120:e2300648120. [PMID: 36943883 PMCID: PMC10068779 DOI: 10.1073/pnas.2300648120] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/08/2023] [Indexed: 03/23/2023] Open
Abstract
Autoantibodies against myelin oligodendrocyte glycoprotein (MOG) have recently been established to define a new disease entity, MOG-antibody-associated disease (MOGAD), which is clinically overlapping with multiple sclerosis. MOG-specific antibodies (Abs) from patients are pathogenic, but the precise effector mechanisms are currently still unknown and no therapy is approved for MOGAD. Here, we determined the contributions of complement and Fc-receptor (FcR)-mediated effects in the pathogenicity of MOG-Abs. Starting from a recombinant anti-MOG (mAb) with human IgG1 Fc, we established MOG-specific mutant mAbs with differential FcR and C1q binding. We then applied selected mutants of this MOG-mAb in two animal models of experimental autoimmune encephalomyelitis. First, we found MOG-mAb-induced demyelination was mediated by both complement and FcRs about equally. Second, we found that MOG-Abs enhanced activation of cognate MOG-specific T cells in the central nervous system (CNS), which was dependent on FcR-, but not C1q-binding. The identification of complement-dependent and -independent pathomechanisms of MOG-Abs has implications for therapeutic strategies in MOGAD.
Collapse
Affiliation(s)
- Simone Mader
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
| | - Samantha Ho
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
- Graduate School of Systemic Neuroscience, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
| | - Hoi Kiu Wong
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
| | - Selia Baier
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
| | - Stephan Winklmeier
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
| | - Carolina Riemer
- Chair of Genetics, Department of Biology, Friedrich Alexander University of Erlangen-Nürnberg, 91058Erlangen, Germany
| | - Heike Rübsamen
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
| | - Iris Marti Fernandez
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
| | - Ramona Gerhards
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
| | - Cuilian Du
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
| | - Omar Chuquisana
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149Münster, Germany
| | - Jan D. Lünemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149Münster, Germany
| | - Anja Lux
- Chair of Genetics, Department of Biology, Friedrich Alexander University of Erlangen-Nürnberg, 91058Erlangen, Germany
| | - Falk Nimmerjahn
- Chair of Genetics, Department of Biology, Friedrich Alexander University of Erlangen-Nürnberg, 91058Erlangen, Germany
- Medical Immunology Campus Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen91058, Germany
| | - Monika Bradl
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, 1090Vienna, Austria
| | - Naoto Kawakami
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
| | - Edgar Meinl
- Institute of Clinical Neuroimmunology, Biomedical Center and University Hospital, Ludwig-Maximilians-Universität München, 82152Planegg-Martinsried, Germany
| |
Collapse
|
27
|
Abstract
Satralizumab (Enspryng®) is a monoclonal antibody that blocks the interleukin-6 (IL-6) receptor and is approved for the treatment of neuromyelitis optica spectrum disorder (NMOSD) in patients who are aquaporin-4 immunoglobulin G (AQP4-IgG) seropositive. Patients with NMOSD are at risk of recurrent autoimmune attacks that primarily target the optic nerves and spinal cord but may also target other regions of the central nervous system; these attacks can lead to life-long disability. In the randomized, placebo-controlled phase III SAkuraSky and SAkuraStar trials, subcutaneous satralizumab as an add-on to immunosuppressive therapy or as a monotherapy, respectively, significantly reduced the risk of relapse compared with placebo in patients who were AQP4-IgG seropositive with NMOSD. Satralizumab was well tolerated; the most common adverse events were infection, headache, arthralgia, decreased white blood cell count, hyperlipidaemia and injection-related reactions. In the EU, satralizumab is the first IL-6 receptor blocker to be approved for treatment of AQP4-IgG-seropositive patients with NMOSD, has the potential advantage of subcutaneous administration, and is the only targeted treatment approved for adolescent patients with this disorder. Thus, satralizumab is a valuable treatment option for patients with NMOSD.
Collapse
|
28
|
Different monoclonal antibodies and immunosuppressants administration in patients with neuromyelitis optica spectrum disorder: a Bayesian network meta-analysis. J Neurol 2023; 270:2950-2963. [PMID: 36884069 DOI: 10.1007/s00415-023-11641-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND A variety of novel monoclonal antibodies and immunosuppressant have been proved effective in treating Neuromyelitis Optica Spectrum Disorder (NMOSD). This network meta-analysis compared and ranked the efficacy and tolerability of currently used monoclonal antibodies and immunosuppressive agents in NMOSD. METHODS Electronic database including PubMed, Embase and Cochrane Library were searched for relevant studies evaluating monoclonal antibodies and immunosuppressants in patients with NMOSD. The primary outcome measures were annualized relapse rate (ARR), relapse rate, the Expanded Disability Status Scale (EDSS) score, and total adverse events (AEs). RESULTS We identified 25 studies with 2919 patients in our meta-analysis. For the primary outcome, rituximab (RTX) (SUCRA: 0.02) ranked first in reduction ARR with a significant difference compared with azathioprine (AZA) (MD - 0.34, 95% CrI - 0.55 to - 0.12) and mycophenolate mofetil (MMF) (MD -0.38, 95% CrI - 0.63 to - 0.14). Tocilizumab (SUCRA: 0.05) ranked first in relapse rate, which was superior to satralizumab (lnOR - 25.4, 95% CrI - 74.4 to - 2.49) and inebilizumab (lnOR - 24.86, 95% CrI - 73.75 to - 1.93). MMF (SUCRA: 0.27) had the fewest AEs followed by RTX (SUCRA: 0.35), both of which showed a significant difference compared with AZA and corticosteroids (MMF vs AZA: lnOR - 1.58, 95% CrI - 2.48 to - 0.68; MMF vs corticosteroids: lnOR - 1.34, 95% CrI - 2.3 to - 0.37) (RTX vs AZA: lnOR - 1.34, 95% CrI - 0.37 to - 2.3; RTX vs corticosteroids: lnOR - 2.52, 95% CrI - 0.32 to - 4.86). In EDSS score, no statistical difference was found between different interventions. CONCLUSION RTX and tocilizumab showed better efficacy than traditional immunosuppressants in reducing relapse. For safety, MMF and RTX had fewer AEs. However, studies with larger sample size on newly developed monoclonal antibodies are warranted in the future.
Collapse
|
29
|
Tkachuk V, Balbuena Aguirre ME, Alonso R, Barboza A, Liwacki SDV, Mainella C, Rojas JI, Silva BA, Tavolini D, Zanga G, López P, Delgado Garcia G, Carnero Contentti E. Barriers to access and unmet needs to neuromyelitis optica spectrum disorders care in an Argentinean cohort. Mult Scler Relat Disord 2023; 70:104485. [PMID: 36610362 DOI: 10.1016/j.msard.2022.104485] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/03/2022] [Accepted: 12/22/2022] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Neuromyelitis optica spectrum disorder (NMOSD) is a rare but severe neuroimmunological condition associated with a significant financial burden. NMOSD is also associated with increased health care utilization, including neurology outpatient visits, magnetic resonance imaging (MRI) use, long-term medication, among others. We aimed to evaluate real-world patient experiences in access to care and NMOSD burden in an Argentinean cohort. METHODS This cross-sectional study used a self-administered survey and was conducted in Argentina (2022). Patients with NMOSD were divided into three groups: private health insurance (PHI), social health insurance (SHI), and public health insurance (PHI, Ministry of Public Health). Differences in access and health care barriers were assessed. RESULTS One hundred patients with NMOSD (74 women) with a mean age at diagnosis of 38.7 years were included. Their EDSS was 2.8 and they were followed for 5.2 years. Of them, 51%, 11%, and 13% were employed (full-time: 57.5%), currently unemployed and retired by NMOSD, respectively. 55% of them visited between 2-3 specialists before NMOSD diagnosis. Aquaporin-4-antibody and/or myelin oligodendrocyte glycoprotein-antibody testing was requested in 91% (health insurance covered this partially in 15.3% and 32.9% of the time the test was entirely paid by patient/family). Patients with NMOSD receiving private medical care reported greater access to MRI, outpatient visits, and fewer issues to obtain NMOSD medications compared to those treated at public institutions. A longer mean time to MRI and neurology visit was found in the PHI group when compared with the other two subgroups. Regression analysis showed that private insurance (OR=3.84, p=0.01) was the only independent factor associated with appropriate access to NMOSD medications in Argentina. CONCLUSION These findings suggest that barriers to access and utilization of NMOSD care services in Argentina are common. NMOSD patients experienced problems to receive NMOSD medication properly, especially those from the public sector.
Collapse
Affiliation(s)
- Verónica Tkachuk
- Neuroimmunology Unit, Department of Neurology, Hospital de Clínicas, Buenos Aires, Argentina
| | | | - Ricardo Alonso
- Centro Universitario de Esclerosis Múltiple -CUEM, Hospital Ramos Mejía, Buenos Aires, Argentina
| | | | - Susana Del Valle Liwacki
- Neurology Unit, Hospital Córdoba, Córdoba, Argentina; Clínica Universitaria Reina Fabiola, Córdoba, Argentina
| | | | - Juan I Rojas
- Service of Neurology, Hospital Universitario de CEMIC, Buenos Aires, Argentina; Centro de Esclerosis Múltiple de Buenos Aires (CEMBA), Buenos Aires, Argentina
| | - Berenice Anabel Silva
- Centro Universitario de Esclerosis Múltiple -CUEM, Hospital Ramos Mejía, Buenos Aires, Argentina; Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Gisela Zanga
- Neurology Unit, Hospital Cesar Milstein, Buenos Aires, Argentina
| | - Pablo López
- Department of Neurosciences, Neuroimmunology Unit, Hospital Alemán, Buenos Aires, Argentina
| | - Guillermo Delgado Garcia
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Centro de Investigación y Desarrollo en Ciencias de la Salud (CIDICS), Universidad Autónoma de Nuevo León, Monterrey, México
| | - Edgar Carnero Contentti
- Department of Neurosciences, Neuroimmunology Unit, Hospital Alemán, Buenos Aires, Argentina.
| |
Collapse
|
30
|
Abstract
PURPOSE OF REVIEW The primary aim of this review is to describe the clinical course, salient imaging features, and relevant serological profiles of common optic neuritis (ON) subtypes. Key diagnostic challenges and treatment options will also be discussed. RECENT FINDINGS ON is a broad term that describes an inflammatory optic nerve injury arising from a variety of potential causes. ON can occur sporadically, however there is particular concern for co-associated central nervous system (CNS) inflammatory syndromes including multiple sclerosis (MS), neuromyelitis optic spectrum disorders (NMOSD), and myelin oligodendrocyte glycoprotein antibody associated disease (MOGAD). The ON subtypes that often herald MS, NMOSD, and MOGAD differ with respect to serological antibody profile and neuroimaging characteristics, yet there is significant overlap in their clinical presentations. A discerning history and thorough examination are critical to rendering the correct diagnosis. SUMMARY Optic neuritis subtypes vary with respect to their long-term prognosis and accordingly, require different acute treatment strategies. Moreover, delays in identifying MOGAD, and certainly NMOSD, can be highly detrimental because affected individuals are vulnerable to permanent vision loss and neurologic disability from relapses.
Collapse
Affiliation(s)
| | - Fiona Costello
- Department of Surgery, Section of Ophthalmology
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
31
|
Carnero Contentti E, López PA, Criniti J, Alonso R, Silva B, Luetic G, Correa-Díaz EP, Galleguillos L, Navas C, Soto de Castillo I, Hamuy FDDB, Gracia F, Tkachuk V, Weinshenker BG, Rojas JI. Frequency of NMOSD misdiagnosis in a cohort from Latin America: Impact and evaluation of different contributors. Mult Scler 2023; 29:277-286. [PMID: 36453614 DOI: 10.1177/13524585221136259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorder (NMOSD) misdiagnosis (i.e. the incorrect diagnosis of patients who truly have NMOSD) remains an issue in clinical practice. We determined the frequency and factors associated with NMOSD misdiagnosis in patients evaluated in a cohort from Latin America. METHODS We retrospectively reviewed the medical records of patients with NMOSD, according to the 2015 diagnostic criteria, from referral clinics in six Latin American countries (Argentina, Chile, Paraguay, Colombia, Ecuador, and Venezuela). Diagnoses prior to NMOSD and ultimate diagnoses, demographic, clinical and paraclinical data, and treatment schemes were evaluated. RESULTS A total of 469 patients presented with an established diagnosis of NMOSD (73.2% seropositive) and after evaluation, we determined that 56 (12%) patients had been initially misdiagnosed with a disease other than NMOSD. The most frequent alternative diagnoses were multiple sclerosis (MS; 66.1%), clinically isolated syndrome (17.9%), and cerebrovascular disease (3.6%). NMOSD misdiagnosis was determined by MS/NMOSD specialists in 33.9% of cases. An atypical MS syndrome was found in 86% of misdiagnosed patients, 50% had NMOSD red flags in brain and/or spinal magnetic resonance imaging (MRI), and 71.5% were prescribed disease-modifying drugs. CONCLUSIONS NMOSD misdiagnosis is relatively frequent in Latin America (12%). Misapplication and misinterpretation of clinical and neuroradiological findings are relevant factors associated with misdiagnosis.
Collapse
Affiliation(s)
| | - Pablo A López
- Neuroimmunology Unit, Department of Neuroscience, Hospital Alemán, Buenos Aires, Argentina
| | - Juan Criniti
- Department of Internal Medicine, Hospital Alemán, Buenos Aires, Argentina
| | - Ricardo Alonso
- Neurology Department, Hospital J.M. Ramos Mejía, University of Buenos Aires, Buenos Aires, Argentina
| | - Berenice Silva
- Neurology Department, Hospital J.M. Ramos Mejía, University of Buenos Aires, Buenos Aires, Argentina/Sección Enfermedades Desmielinizantes, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Lorna Galleguillos
- Clínica Alemana de Santiago, Santiago, Chile; Universidad del Desarrollo, Santiago, Chile
| | - Carlos Navas
- Clínica Enfermedad Desmielinizante, Clinica Universitaria Colombia, Bogotá, Colombia
| | | | | | - Fernando Gracia
- Hospital Santo Tomas, Universidad Interamericana de Panamá, Panama City, Panamá
| | - Verónica Tkachuk
- Neuroimmunology Section, Department of Neurology, Hospital de Clínicas "José de San Martín," Buenos Aires, Argentina
| | | | - Juan Ignacio Rojas
- Centro de Esclerosis Múltiple de Buenos Aires (CEMBA), Buenos Aires, Argentina
| |
Collapse
|
32
|
Anti-BCMA CAR T-cell therapy CT103A in relapsed or refractory AQP4-IgG seropositive neuromyelitis optica spectrum disorders: phase 1 trial interim results. Signal Transduct Target Ther 2023; 8:5. [PMID: 36596762 PMCID: PMC9810610 DOI: 10.1038/s41392-022-01278-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/09/2022] [Accepted: 11/13/2022] [Indexed: 01/05/2023] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy that targets B-cell maturation antigen (BCMA) have great potentials in autoimmune diseases and could be novel therapeutics for relapsed/refractory neuromyelitis optica spectrum disorder (NMOSD). To evaluate the safety and efficacy of the CT103A, a self-developed BCMA-targeting CAR construct against BCMA, in patients with AQP4-IgG seropositive NMOSD, an ongoing, investigator-initiated, open-label, single-arm, phase 1 clinical trial is conducted at our center. In total, 12 patients were administered with a CAR-BCMA infusion. Ten of the 12 patients dosed were women (83.3%), with a median age of 49.5 years (range, 30-67). were The most common events of grade 3 or higher were hematologic toxic effects. Seven patients (58%) developed infections, but no grade 4 infections occurred. Cytokine release syndrome was reported in all patients with only events of grade 1 or 2 observed. During the follow-up of a median 5.5 months, 11 patients had no relapse; all patients generally reported improvement in disabilities and quality-of-life outcomes; 11 patients' AQP-4 antibodies in serum showed a downward trend by the cutoff date. CAR T-cell expansion was associated with responses, and persisted more than 6 months post-infusion in 17% of the patients. In summary, CAR T-cell therapy shows a manageable safety profile and therapeutic potentials for patients with relapsed/refractory AQP4-IgG seropositive NMOSD. Another expansion phase is currently underway to determine the safety and efficacy of CAR T-BCMA infusion in patients with other neuro-inflammatory diseases.
Collapse
|
33
|
Bennett JL, Costello F, Chen JJ, Petzold A, Biousse V, Newman NJ, Galetta SL. Optic neuritis and autoimmune optic neuropathies: advances in diagnosis and treatment. Lancet Neurol 2023; 22:89-100. [PMID: 36155661 DOI: 10.1016/s1474-4422(22)00187-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 01/04/2023]
Abstract
Optic neuritis is an inflammatory optic neuropathy that is commonly indicative of autoimmune neurological disorders including multiple sclerosis, myelin-oligodendrocyte glycoprotein antibody-associated disease, and neuromyelitis optica spectrum disorder. Early clinical recognition of optic neuritis is important in determining the potential aetiology, which has bearing on prognosis and treatment. Regaining high-contrast visual acuity is common in people with idiopathic optic neuritis and multiple sclerosis-associated optic neuritis; however, residual deficits in contrast sensitivity, binocular vision, and motion perception might impair vision-specific quality-of-life metrics. In contrast, recovery of visual acuity can be poorer and optic nerve atrophy more severe in individuals who are seropositive for antibodies to myelin oligodendrocyte glycoprotein, AQP4, and CRMP5 than in individuals with typical optic neuritis from idiopathic or multiple-sclerosis associated optic neuritis. Key clinical, imaging, and laboratory findings differentiate these disorders, allowing clinicians to focus their diagnostic studies and optimise acute and preventive treatments. Guided by early and accurate diagnosis of optic neuritis subtypes, the timely use of high-dose corticosteroids and, in some instances, plasmapheresis could prevent loss of high-contrast vision, improve contrast sensitivity, and preserve colour vision and visual fields. Advancements in our knowledge, diagnosis, and treatment of optic neuritis will ultimately improve our understanding of autoimmune neurological disorders, improve clinical trial design, and spearhead therapeutic innovation.
Collapse
Affiliation(s)
- Jeffrey L Bennett
- Department of Neurology and Department of Ophthalmology, Programs in Neuroscience and Immunology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Fiona Costello
- Departments of Clinical Neurosciences and Surgery, University of Calgary, Calgary, AB, Canada
| | - John J Chen
- Department of Ophthalmology and Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Axel Petzold
- National Hospital for Neurology and Neurosurgery, University College London Hospital, London, UK; Moorfields Eye Hospital, London, UK; Neuro-ophthalmology Expert Centre, Amsterdam, Netherlands
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven L Galetta
- Department of Neurology and Department of Opthalmology, NYU Langone Medical Center, New York, NY, USA
| |
Collapse
|
34
|
Krasnov VS, Bakhtiyarova KZ, Evdoshenko EP, Korobko DS, Simaniv TO, Totolyan NA, Khachanova NV, Shumilina MV, Davydovskaya MV. Consensus opinion on the management of patients with neuromyelitis optica spectrum diseases: issues of terminology and therapy. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2022. [DOI: 10.14412/2074-2711-2022-6-139-148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- V. S. Krasnov
- Acad. I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia
| | | | - E. P. Evdoshenko
- City Center for Multiple Sclerosis, City Clinical Hospital Thirty-One
| | - D. S. Korobko
- Regional Center of Multiple Sclerosis and other Autoimmune Diseases of Nervous system, Novosibirsk State Regional Clinical Hospital; Novosibirsk State Medical University, Ministry of Health of Russia
| | | | - N. A. Totolyan
- Acad. I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia
| | - N. V. Khachanova
- N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia; Interdistrict Department of Multiple Sclerosis, City Clinical Hospital No 24, Moscow Healthcare Department
| | - M. V. Shumilina
- Acad. I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia; City Center for Multiple Sclerosis, City Clinical Hospital Thirty-One
| | - M. V. Davydovskaya
- N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia; Research and Practical Center for Clinical and Economic Analysis, Ministry of Health of the Moscow Region
| |
Collapse
|
35
|
Wingerchuk DM, Weinshenker BG, McCormick D, Barron S, Simone L, Jarzylo L. Aligning payer and provider strategies with the latest evidence to optimize clinical outcomes for patients with neuromyelitis optica spectrum disorder. J Manag Care Spec Pharm 2022; 28:S3-S27. [DOI: 10.18553/jmcp.2022.28.12-a.s1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
36
|
Different doses of Rituximab for the therapy of Neuromyelitis optica spectrum disorder: A systematic review and meta-analysis. Mult Scler Relat Disord 2022; 68:104127. [PMID: 36044828 DOI: 10.1016/j.msard.2022.104127] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/27/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neuromyelitis optica spectrum disease(NMOSD) is an autoimmune neurological disease that primarily affects the spinal cord, optic nerve, and periventricular organs. Rituximab plays an important role in the prevention of relapse in NMOSD. In this study, we evaluated the efficacy and safety of different doses of the anti-monoclonal antibody rituximab in NMOSD. OBJECTS Our study aimed to implement a meta-analysis to systematically assess the efficacy and safety of different doses of rituximab in the treatment of NMOSD. METHODS We searched Pubmed, Embase, the Cochrane Library, and Clinicaltrials.gov for relevant studies evaluating rituximab for NMOSD up to March 2022. Data were assessed using Review Manager 5.3 and Stata 14 softwares. Means and standard deviations(SD) were analyzed using random effects models with continuous outcomes. Risk radio was analyzed using random effects models with dichotomous outcomes. RESULTS We collected 576 patients from 17 studies. The endpoint of efficacy was the change in annual recurrence rate(ARR), expanded disability status scale (EDSS), and the number of patients free of relapse between pre-treatment and post-treatment of rituximab. We found that rituximab reduced ARR and EDSS, with a significant reduction in ARR(MD= -1.79, 95% CI: -3.18 ∼ -0.39, P= 0.01) and EDSS(MD= -1.35, 95% CI: -1.5 ∼ -1.19, P < 0.00001) at 100 mg intravenous infusion per week for 3 consecutive weeks, meanwhile making the number of patients free of relapse increased (RR= 24.61 [5.11, 118.55], P<0.0001) and being relatively safe and without serious adverse events(SAEs). In terms of safety, we compared and summarised the adverse events(AEs) and SAEs from 17 studies. CONCLUSION In this study, we found rituximab to be relatively safe and efficacious in the treatment of NMOSD, particularly at a dose of 100mg intravenous infusion per week for 3 consecutive weeks.
Collapse
|
37
|
Should Aquaporin-4 Antibody Test Be Performed in all Patients With Isolated Optic Neuritis? J Neuroophthalmol 2022; 42:454-461. [PMID: 36255079 DOI: 10.1097/wno.0000000000001573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Optic neuritis (ON) may be the initial manifestation of neuromyelitis optica spectrum disorder (NMOSD). Aquaporin-4 antibody (AQP4 Ab) is used to diagnose NMOSD. This has implications on prognosis and is important for optimal management. We aim to evaluate if clinical features can distinguish AQP4 Ab seropositive and seronegative ON patients. METHODS We reviewed patients with first episode of isolated ON from Tan Tock Seng Hospital and Singapore National Eye Centre who tested for AQP4 Ab from 2008 to 2017. Demographic and clinical data were compared between seropositive and seronegative patients. RESULTS Among 106 patients (120 eyes) with first episode of isolated ON, 23 (26 eyes; 22%) were AQP4 Ab positive and 83 (94 eyes; 78%) were AQP4 Ab negative. At presentation, AQP4 Ab positive patients had older mean onset age (47.9 ± 13.6 vs 36.8 ± 12.6 years, P < 0.001), worse nadir VA (OR 1.714; 95% CI, 1.36 to 2.16; P < 0.001), less optic disc swelling (OR 5.04; 95% CI, 1.682 to 15.073; p = 0.004), and higher proportions of concomitant anti-Ro antibody (17% vs 4%, p = 0.038) and anti-La antibody (17% vs 1%, p = 0.008). More AQP4 Ab positive patients received steroid-sparing immunosuppressants (74% vs 19%, p < 0.001) and plasma exchange (13% vs 0%, p = 0.009). AQP4 Ab positive patients had worse mean logMAR VA (visual acuity) at 12 months (0.70 ± 0.3 vs 0.29 ± 0.5, p = 0.051) and 36 months (0.37±0.4 vs 0.14 ± 0.2, p = 0.048) follow-up. CONCLUSION Other than older onset age and retrobulbar optic neuritis, clinical features are non-discriminatory for NMOSD. We propose a low threshold for AQP4 Ab serology testing in inflammatory ON patients, particularly in high NMOSD prevalence populations, to minimize diagnostic and treatment delays.
Collapse
|
38
|
Vishnevetsky A, Kaplan TB, Levy M. Transitioning immunotherapy in neuromyelitis optica spectrum disorder – when and how to switch. Expert Opin Biol Ther 2022; 22:1393-1404. [DOI: 10.1080/14712598.2022.2145879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Anastasia Vishnevetsky
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Tamara B. Kaplan
- Department of Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael Levy
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
39
|
Shi Z, Du Q, Wang X, Wang J, Chen H, Lang Y, Kong L, Luo W, Yang M, Zhou H. Granzyme B in circulating CD8+ T cells as a biomarker of immunotherapy effectiveness and disability in neuromyelitis optica spectrum disorders. Front Immunol 2022; 13:1027158. [PMID: 36439094 PMCID: PMC9682179 DOI: 10.3389/fimmu.2022.1027158] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/21/2022] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Neuromyelitis optica spectrum disorders (NMOSD) are chronical inflammatory demyelinating diseases of the central nervous system (CNS) and the underlying mechanism remains unclear. Several recent studies have demonstrated that T cells play a pivotal role in the pathogenesis of NMOSD.In this study, we investigated CD8+ T cell phenotypes and levels of the cytotoxic protein granzyme B (GzmB), as well as their potential clinical application in NMOSD. METHODS In this study, 90 peripheral blood samples were collected from 59 NMOSD patients with seropositive anti-aquaporin-4 (AQP4) antibodies and 31 sex- and age-matched healthy donors (HDs). Flow cytometry was used to detect circulating levels of GzmB and CD8+ T cell subpopulations, including naïve (TN, CCD7+CD45RA+), central memory (TCM, CCD7+CD45RA-), effector memory (TEM, CCD7-CD45RA-), terminal differentiation effector memory cells (TEMRA, CCD7-CD45RA+) in both groups. The associations between GzmB levels in CD8+T cells and clinical characteristics of NMOSD were evaluated. RESULTS NMOSD patients exhibited significantly decreased proportions of CD8+TN cells and increased proportions of highly differentiated CD8+T cells (TEMRA) compared with HDs. In addition, levels of GzmB in CD8+ T cells were markedly higher in NMOSD patients than in HDs. Moreover, we observed that high proportions of GzmB-expressing CD8+ T cells were more common in patients with a poor response to immunotherapies, and showed a good potential to distinguish poor responders from responders (ACU=0.89). Clinical correlation analysis indicated that high levels of GzmB in CD8+ T cells were not only related to severe disability but also significantly associated with increased serum levels of neurofilament light (NFL) and glial fibrillary acidic protein (GFAP). Multivariate linear regression analyses further suggested that GzmB expression in CD8+ T cells was predominantly associated with disability and immunotherapy effectiveness in NMOSD, independent of the sex, age, and disease phase. Transcription factor T-bet in CD8+ T cells were also significantly elevated in NMOSD and were associated with increasing number of circulating CD8+TEMRA cells and GzmB-expressing CD8+T cells. CONCLUSIONS Our study support the involvement of GzmB-expressing CD8+ T cells in the inflammatory response in patients with NMOSD and provide a potential biomarker for disease immunotherapy effectiveness and disability progression.
Collapse
Affiliation(s)
- Ziyan Shi
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Qin Du
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaofei Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jianchen Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Hongxi Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yanling Lang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Lingyao Kong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Wenqin Luo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mu Yang
- Centre for Translational Research in Cancer, Sichuan Cancer Hospital & Institute, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
40
|
Jiao L, Guo S. Anti-IL-6 therapies in central nervous system inflammatory demyelinating diseases. Front Immunol 2022; 13:966766. [PMID: 36389702 PMCID: PMC9647084 DOI: 10.3389/fimmu.2022.966766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 09/20/2022] [Indexed: 08/11/2023] Open
Abstract
Current treatments for central nervous system (CNS) inflammatory demyelinating diseases (IDDs) include corticosteroids, plasma exchange, intravenous immunoglobulin, and immunosuppressant drugs. However, some patients do not respond well to traditional therapies. In recent years, novel drugs, such as monoclonal antibodies, targeting the complement component C5, CD19 on B cells, and the interleukin-6 (IL-6) receptor, have been used for the treatment of patients with refractory CNS IDDs. Among these, tocilizumab and satralizumab, humanized monoclonal antibodies against the IL-6 receptor, have shown beneficial effects in the treatment of this group of diseases. In this review, we summarize current research progress and prospects relating to anti-IL-6 therapies in CNS IDDs.
Collapse
Affiliation(s)
- Li Jiao
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Shougang Guo
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| |
Collapse
|
41
|
Krasnov VS, Prakhova LN, Totolyan NA. Current view on the diagnosis and treatment of neuromyelitis optica spectrum disorders exacerbations. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2022. [DOI: 10.14412/2074-2711-2022-5-69-76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Irreversible neurological deficit and disability in neuromyelitis optica spectrum disorders (NOSD) are formed as a result of exacerbations, which are often life-threatening. Timely diagnosis and treatment of exacerbations is a key task in the management of this category of patients. A unified structured approach to the diagnosis and treatment of NOSD exacerbations has not been developed. The purpose of this article is to analyze the scientific literature data on this issue in order to optimize the diagnostics and treatment of NOSD exacerbations in everyday clinical practice.
Collapse
Affiliation(s)
- V. S. Krasnov
- Acad. I.P. Pavlov First Saint Petersburg State Medical University of Ministry of Health of Russia
| | - L. N. Prakhova
- N.P. Bekhtereva Human Brain Institute, Russian Academy of Sciences
| | - N. A. Totolyan
- Acad. I.P. Pavlov First Saint Petersburg State Medical University of Ministry of Health of Russia
| |
Collapse
|
42
|
Benard-Seguin E, Costello F. A Practical Approach to the Diagnosis and Management of Optic Neuritis. Ann Indian Acad Neurol 2022; 25:S48-S53. [PMID: 36589032 PMCID: PMC9795707 DOI: 10.4103/aian.aian_170_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/19/2022] [Indexed: 01/04/2023] Open
Abstract
Optic neuritis (ON), as an umbrella term, refers to a spectrum of inflammatory optic neuropathies arising from a myriad of potential causes. In its most common form, "typical" ON presents as a unilateral, painful subacute vision loss event in young Caucasian women. The Optic Neuritis Treatment Trial (ONTT) has historically guided our treatment of ON, and taught us important lessons about the clinical presentation, visual prognosis, and future risk of multiple sclerosis (MS) diagnosis associated with this condition. However, in the decades since the ONTT, several immune-mediated conditions such as neuromyelitis optica spectrum disorder (NMOSD), and myelin-oligodendrocyte glycoprotein IgG associated disease (MOGAD) have been discovered, complicating the clinical approach to ON. Unlike MS, other central nervous system (CNS) inflammatory conditions are associated with ON subtypes that are potentially blinding, and prone to recurrence. Owing to differences in the clinical presentation, serological biomarkers, radiological findings, and prognostic implications associated with MS ON, NMOSD ON, and MOGAD ON subtypes, it is imperative that clinicians be aware of the diagnostic approach and management options for these conditions.
Collapse
Affiliation(s)
| | - Fiona Costello
- Department of Surgery in Ophthalmology, University of Calgary, Calgary, AB, Canada,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada,Address for correspondence: Dr. Fiona Costello, 7007 14 St SW, Calgary, AB T2V 1P9, Calgary, Alberta, Canada. E-mail:
| |
Collapse
|
43
|
Abstract
Inebilizumab (Uplizna®) is a recently approved monoclonal antibody for use in adults with neuromyelitis optica spectrum disorder (NMOSD) who are anti-aquaporin-4 (AQP4) antibody seropositive. Inebilizumab targets the B cell antigen CD19 and effectively depletes circulating B cells, thus suppressing inflammatory NMOSD attacks that are potentially disabling or life-threatening. It is approved as an intravenous infusion in several countries. In the pivotal phase 2/3 N-MOmentum trial, inebilizumab reduced the risk of NMOSD attacks compared with placebo, including in AQP4-antibody seropositive patients. Inebilizumab also significantly reduced the risk of disability score worsening, the number of NMOSD-related hospitalisations and MRI lesion count, but had no significant effect on low-contrast binocular vision. The treatment effect on relapse risk and disability scores was sustained in inebilizumab-treated patients for ≥ 4 years during the open-label extension. Inebilizumab was generally well tolerated, with the most common adverse events being urinary tract infection and arthralgia. Thus, inebilizumab is an effective treatment option for adults with AQP4-antibody seropositive NMOSD.
Collapse
Affiliation(s)
- Tina Nie
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
| | - Hannah A Blair
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand
| |
Collapse
|
44
|
Chen TX, Fan YT, Peng BW. Distinct mechanisms underlying therapeutic potentials of CD20 in neurological and neuromuscular disease. Pharmacol Ther 2022; 238:108180. [DOI: 10.1016/j.pharmthera.2022.108180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/16/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
|
45
|
Treatment and Relapse Prevention of Typical and Atypical Optic Neuritis. Int J Mol Sci 2022; 23:ijms23179769. [PMID: 36077167 PMCID: PMC9456305 DOI: 10.3390/ijms23179769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 12/02/2022] Open
Abstract
Optic neuritis (ON) is an inflammatory condition involving the optic nerve. Several important typical and atypical ON variants are now recognized. Typical ON has a more favorable prognosis; it can be idiopathic or represent an early manifestation of demyelinating diseases, mostly multiple sclerosis (MS). The atypical spectrum includes entities such as antibody-driven ON associated with neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD), chronic/relapsing inflammatory optic neuropathy (CRION), and sarcoidosis-associated ON. Appropriate and timely diagnosis is essential to rapidly decide on the appropriate treatment, maximize visual recovery, and minimize recurrences. This review paper aims at presenting the currently available state-of-the-art treatment strategies for typical and atypical ON, both in the acute phase and in the long-term. Moreover, emerging therapeutic approaches and novel steps in the direction of achieving remyelination are discussed.
Collapse
|
46
|
Shah SS, Morris P, Buciuc M, Tajfirouz D, Wingerchuk DM, Weinshenker BG, Eggenberger ER, Di Nome M, Pittock SJ, Flanagan EP, Bhatti MT, Chen JJ. Frequency of Asymptomatic Optic Nerve Enhancement in a Large Retrospective Cohort of Patients With Aquaporin-4+ NMOSD. Neurology 2022; 99:e851-e857. [PMID: 35697504 PMCID: PMC9484733 DOI: 10.1212/wnl.0000000000200838] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/22/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Asymptomatic or persistent optic nerve enhancement in aquaporin-4 (AQP4)-immunoglobulin G (IgG)-positive neuromyelitis optica spectrum disorder (NMOSD) is thought to be rare. Improved understanding may have important implications for assessment of treatment efficacy in clinical trials and in clinical practice. Our objective was to characterize NMOSD interattack optic nerve enhancement. METHODS This was a retrospective cohort study performed between 2000 and 2019 (median follow-up 5.5 [range 1-35] years) of patients with AQP4-IgG-positive optic neuritis (ON) evaluated at Mayo Clinic. MRI orbits were reviewed by a neuroradiologist, neuro-ophthalmologist, and neuroimmunologist blinded to the clinical history. Interattack optic nerve enhancement (>30 days after attack) was measured. The correlation between interattack enhancement and Snellen visual acuity (VA), converted to logarithm of the minimum angle of resolution (logMAR), at attack and at follow-up were assessed. RESULTS A total of 198 MRI scans in 100 patients with AQP4-IgG+ NMOSD were identified, with 107 interattack MRIs from 78 unique patients reviewed. Seven scans were performed before any ON (median 61 days before attack [range 21-271 days]) and 100 after ON (median 400 days after attack [33-4,623 days]). Optic nerve enhancement was present on 18/107 (16.8%) interattack scans (median 192.5 days from attack [33-2,943]) of patients with preceding ON. On 15 scans, enhancement occurred at the site of prior attacks; the lesion location was unchanged, but the lesion length was shorter. Two scans (1.8%) demonstrated new asymptomatic lesions (prior scan demonstrated no enhancement). In a third patient with subjective blurry vision, MRI showed enhancement preceding detectable eye abnormalities on examination noted 15 days later. There was no difference in VA at preceding attack nadir (logMAR VA 1.7 vs 2.1; p = 0.79) or long-term VA (logMAR VA 0.4 vs 0.2, p = 0.56) between those with and without interattack optic nerve enhancement. DISCUSSION Asymptomatic optic nerve enhancement occurred in 17% of patients with NMOSD predominantly at the site of prior ON attacks and may represent intermittent blood-brain barrier breakdown or subclinical ON. New asymptomatic enhancement was seen only in 2% of patients. Therapeutic clinical trials for NMOSD require blinded relapse adjudication when assessing treatment efficacy, and it is important to recognize that asymptomatic optic nerve enhancement can occur in patients with ON.
Collapse
Affiliation(s)
- Shailee S Shah
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Pearse Morris
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Marina Buciuc
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Deena Tajfirouz
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Dean M Wingerchuk
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Brian G Weinshenker
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Eric R Eggenberger
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Marie Di Nome
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Sean J Pittock
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - Eoin P Flanagan
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - M Tariq Bhatti
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN
| | - John J Chen
- From the Department of Neurology (S.S.S., M.B., D.T., B.G.W., S.J.P., E.P.F., M.T.B., J.J.C.), and Center for Multiple Sclerosis and Autoimmune Neurology (S.S.S., M.B., D.M.W., B.G.W., S.J.P., E.P.F., J.J.C.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.S.), Vanderbilt University Medical Center, Nashville TN; Department of Radiology (P.M.), Mayo Clinic, Rochester, MN; Department of Neurology (D.M.W.), Mayo Clinic, Scottsdale, AZ; Department of Ophthalmology (E.R.E.), Mayo Clinic, Jacksonville, FL; Department of Ophthalmology (M.D.N.), Mayo Clinic, Scottsdale, AZ; Department of Lab Medicine and Pathology (S.J.P., E.P.F.), and Department of Ophthalmology (M.T.B., J.J.C.), Mayo Clinic, Rochester, MN.
| |
Collapse
|
47
|
Affiliation(s)
- Dean M Wingerchuk
- From the Department of Neurology, Mayo Clinic, Scottsdale, AZ (D.M.W.); and the Department of Neurology, Mayo Clinic, Rochester, MN (C.F.L.)
| | - Claudia F Lucchinetti
- From the Department of Neurology, Mayo Clinic, Scottsdale, AZ (D.M.W.); and the Department of Neurology, Mayo Clinic, Rochester, MN (C.F.L.)
| |
Collapse
|
48
|
Abstract
PURPOSE OF REVIEW This article reviews the cardinal clinical features, distinct immunopathology, current diagnostic criteria, relapse-related risk factors, emerging biomarkers, and evolving treatment strategies pertaining to neuromyelitis optica spectrum disorders (NMOSD). RECENT FINDINGS The discovery of the pathogenic aquaporin-4 (AQP4)-IgG autoantibody and characterization of NMOSD as an autoimmune astrocytopathy have spearheaded the identification of key immunologic therapeutic targets in this disease, including but not limited to the complement system, the interleukin 6 (IL-6) receptor, and B cells. Accordingly, four recent randomized controlled trials have demonstrated the efficacy of three new NMOSD therapies, namely eculizumab, satralizumab, and inebilizumab. SUMMARY Currently, NMOSD poses both diagnostic and treatment challenges. It is debated whether individuals who are seropositive for myelin oligodendrocyte glycoprotein (MOG)-IgG belong within the neuromyelitis optica spectrum. This discussion is fueled by disparities in treatment responses between patients who are AQP4-IgG seropositive and seronegative, suggesting different immunopathologic mechanisms may govern these conditions. As our understanding regarding the immune pathophysiology of NMOSD expands, emerging biomarkers, including serum neurofilament light chain and glial fibrillary acidic protein (GFAP), may facilitate earlier relapse detection and inform long-term treatment decisions. Future research focal points should include strategies to optimize relapse management, restorative treatments that augment neurologic recovery, and practical solutions that promote equitable access to approved therapies for all patients with NMOSD.
Collapse
|
49
|
Costello F, Burton JM. Contemporary management challenges in seropositive NMOSD. J Neurol 2022; 269:5674-5681. [PMID: 35816205 PMCID: PMC9272395 DOI: 10.1007/s00415-022-11241-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022]
Abstract
Neuromyelitis optica spectrum disorders (NMOSD) is an inflammatory disorder of the central nervous system that presents unique management challenges. Neurologic disability in NMOSD is directly linked to acute attacks, therefore, relapse prevention is an overarching goal of care. To this end, identifying effective biomarkers that predict relapse onset and severity is of critical importance. As treatment becomes more precision-based and patient-centred, clinicians will need to be familiar with managing circumstances of particular vulnerability for patients with NMOSD, including infection, pregnancy, and the post-partum phase. The discovery of the pathogenic aquaporin-4 Immunoglobulin G (AQP4 IgG) autoantibody almost 20 years ago ultimately distinguished NMOSD as an autoimmune astrocytopathy and helped spearhead recent therapeutic advancements. Targeted therapies, including eculizumab, satralizumab, and inebilizumab, approved for use in aquaporin-4 immunoglobulin G (AQP4 IgG) seropositive patients with NMOSD will likely improve outcomes, but there are formidable costs involved. Importantly, seronegative patients continue to have limited therapeutic options. Moving forward, areas of research exploration should include relapse prevention, restorative therapies, and initiatives that promote equitable access to approved therapies for all people living with NMOSD.
Collapse
Affiliation(s)
- Fiona Costello
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
- Department of Surgery, University of Calgary, Calgary, Canada.
| | - Jodie M Burton
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| |
Collapse
|
50
|
Shi M, Chu F, Jin T, Zhu J. Progress in treatment of neuromyelitis optica spectrum disorders (NMOSD): Novel insights into therapeutic possibilities in NMOSD. CNS Neurosci Ther 2022; 28:981-991. [PMID: 35426485 PMCID: PMC9160456 DOI: 10.1111/cns.13836] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/18/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune inflammatory demyelinating disorder of the central nervous system (CNS), which is a severely disabling disorder leading to devastating sequelae or even death. Repeated acute attacks and the presence of aquaporin-4 immunoglobulin G (AQP4-IgG) antibody are the typical characteristics of NMOSD. Recently, the phase III trials of the newly developed biologicals therapies have shown their effectiveness and good tolerance to a certain extent when compared with the traditional therapy with the first- and second-line drugs. However, there is still a lack of large sample, double-blind, randomized, clinical studies to confirm their efficacy, safety, and tolerability. Especially, these drugs have no clear effect on NMOSD patients without AQP4-IgG and refractory patients. Therefore, it is of strong demand to further conduct large sample, double-blind, randomized, clinical trials, and novel therapeutic possibilities in NMOSD are discussed briefly here.
Collapse
Affiliation(s)
- Mingchao Shi
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Department of Neurobiology, Care Sciences & Society, Division of Neurogeriatrcs, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Fengna Chu
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Department of Neurobiology, Care Sciences & Society, Division of Neurogeriatrcs, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Tao Jin
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Jie Zhu
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Department of Neurobiology, Care Sciences & Society, Division of Neurogeriatrcs, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| |
Collapse
|