Diagnosis of myelin oligodendrocyte glycoprotein antibody-associated disease: International MOGAD Panel proposed criteria

Permeability of the blood-CSF barrier in MOGAD: clinical correlation based on the 2023 diagnostic criteria

BACKGROUND

The pathogenesis of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is associated with damage to the blood-cerebrospinal fluid (CSF) barrier (BCB), but a specific correlation remains unclear. We used the newly proposed diagnostic criteria in 2023 with the aim to evaluate the permeability of the BCB in MOGAD.

METHODS

We retrospectively analyzed data from 48 eligible patients with MOGAD. Serum and CSF samples were collected simultaneously prior to initiation of immunotherapies at admission. Elevated CSF/serum albumin quotient (QAlb) and indicators of intrathecal immunoglobulin G (IgG) synthesis were calculated as indicators of BCB damage. The relationship between the parameters and clinical features, disease severity, and prognosis were analyzed.

RESULTS

Elevated QAlb levels were detected in 50% of patients, but only a small proportion of patients met the corresponding classifications of intrathecal IgG synthesis, namely IgG index >0.7 (10.4%), IgG synthesis rate >10 (6.2%), and local IgG synthesis rate >0 (8.1%). Elevated QAlb was significantly more common in patients with myelitis than in those with optic neuritis (p = 0.049). It was identified as an independent predictor of moderate-severe disease at admission (modified Rankin Scale [mRS]/Expanded Disability Status Scale [EDSS] ≥ 4). Moreover, elevated QAlb emerged as an independent risk factor for a poor long-term prognosis (mRS/EDSS ≥3 at the last follow-up).

CONCLUSIONS

BCB damage was common in MOGAD. Elevated QAlb could serve as a biomarker for evaluating disease severity at admission and predicting long-term prognosis.

Abnormal Brain MRI in Anti-NMDA Receptor Encephalitis: Clinical and Prognostic Implications

BACKGROUND AND OBJECTIVES

Abnormal brain MRI is associated with poor outcomes in anti-N-methyl-d-aspartate receptor encephalitis (NMDARE). We aimed to characterize the lesions on brain MRI in NMDARE and to assess the clinical and prognostic associations.

METHODS

This retrospective cohort study included patients with NMDARE identified at the French Reference Center for Autoimmune Encephalitis, with at least a one-year follow-up, and with available brain MRI results. In case of brain extralimbic lesion, the image files were reviewed when available. Clinical data were collected from medical records. Multivariable logistic regression analysis was used to study the outcomes at 2-year follow-up; recovery was defined as modified Rankin Scale score ≤1.

RESULTS

Among the 255 patients included, 37 (14.5%) had limbic hyperintensities and 41 (16.1%) had extralimbic lesions that included multiple sclerosis (MS)-like lesions (14/41, 34.1%); extensive lesions (5/41, 12.2%); and poorly demarcated fluffy lesions, either multifocal (10/41, 24.4%) or involving the cerebral cortex or cerebellum (6/41 each, 14.6%). Extralimbic lesions coexisting with limbic lesions (19/41 patients, 46.3%) were mostly fluffy lesions (11/19, 57.9%). Ten patients had overlapping demyelinating syndromes: 4 with MS, 4 with myelin oligodendrocyte glycoprotein-associated disorder, and 2 with neuromyelitis optica spectrum disorder; all had MS-like (7/10 patients) or extensive (3/10 patients) lesions, and none had fluffy lesions. Extralimbic lesions were associated with symptoms nontypical for NMDARE (23/41, 56.1%, p < 0.001), especially cerebellar ataxia (17/41, 41.5%) and motor impairment (12/41, 29.3%). At 2 years, patients with MS-like or extensive lesions had a lower recovery rate (5/12, 41.7%, and 1/4, 25%, respectively) compared with the patients without extralimbic lesions (124/162, 76.5%; p = 0.014 and p = 0.047, respectively). In multivariable analysis, MS-like lesions, but not hippocampal nor fluffy lesions, were associated with absence of recovery at 2 years (adjusted OR 0.1, 95% CI 0.03-0.42, p = 0.002; extensive lesions [n = 4] not included in the analysis).

DISCUSSION

Brain MRI lesions in NMDARE include limbic hyperintensities and 3 patterns of extralimbic lesions, which are associated with nontypical NMDARE symptoms. Moreover, MS-like and extensive lesions, but not fluffy nor hippocampal lesions, are associated with overlapping demyelinating syndromes and poor clinical outcomes at 2 years. These findings can have practical implications on the monitoring of patients with NMDARE.

Investigation into the casual or causal association of cerebral venous thrombosis and myelin oligodendrocyte glycoprotein antibody‑associated disease: A case report and literature review

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a central nervous system demyelinating syndrome (DS) typically presenting with optic neuritis or myelitis. The association between cerebral venous thrombosis (CVT) and demyelinating diseases, including multiple sclerosis (MS), is rare. In the present study, a 37-year-old man presented with sensory disturbances in the lower limbs and urinary incontinence, consistent with myelitis. The diagnosis of MOGAD was confirmed by spinal magnetic resonance imaging findings and serum anti-MOG antibody positivity using a cell-based assay. The patient responded successfully to intravenous corticosteroid therapy. However, shortly after recovery, the patient developed a persistent headache and suffered an epileptic seizure, which was later attributed to CVT. The patient was treated with low molecular weight heparin and lacosamide and subsequently returned to baseline health status without seizure recurrence in the following year. Comprehensive review of the literature on CVT associated with DS, encompassing 15 case reports, two case series and two studies, underscores the rarity of this condition. Most reported cases of CVT have been linked to MS, while only three cases of CVT associated with MOGAD have been documented to date. Additional risk factors, such as lumbar puncture and high-dose corticosteroid treatment, have been implicated in some instances. Given their shared inflammatory basis, a thrombotic-inflammatory pathogenic mechanism acting between DS and CVT in predisposed individuals is plausible. However, the exact pathogenic association between these conditions remains largely unclear, and a coincidental association cannot be ruled out. The role of anti-MOG antibodies in this rare condition also warrants further investigation.

"Will the Real Demyelinating Disorder Please Stand Up?": From the National Multiple Sclerosis Society Case Conference Proceedings

A 46-year-old man presented with progressive painful monocular vision loss and left leg paresthesias. Workup demonstrated multifocal demyelinating lesions and CSF-restricted oligoclonal bands. He was diagnosed with multiple sclerosis (MS), but follow-up testing was notable for positive myelin oligodendrocyte glycoprotein-immunoglobulin G (MOG-IgG). We discuss implications and clinical considerations for MOG-IgG positivity in MS.

Diagnostic Utility of Kappa Free Light Chain Index in Adults With Inaugural Optic Neuritis

BACKGROUND AND OBJECTIVES

A simple, quick, and reproducible procedure for distinguishing multiple sclerosis (MS), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and neuromyelitis optica spectrum disorder (NMOSD) at inaugural optic neuritis (ION) could be highly valuable in guiding early management.

METHODS

We included all adults admitted to the MS center of Marseille for ION between March 2016 and April 2024, with CSF analysis including the kappa free light chain (K-FLC) index. Receiver operating characteristic curves were used to measure the diagnostic ability of the K-FLC index.

RESULTS

Two hundred twenty-seven adults were admitted for ION; 210 (93%) had a K-FLC index measurement. MS was diagnosed in 84 (40%); clinically isolated syndrome suggestive of MS in 77 (36.5%), including 20 with future conversion to MS (CISwc); MOGAD in 26 (12.5%); NMOSD in 13 (6%); and other inflammatory disorders in 10 (5%). A K-FLC index ≥6.7 differentiated MS/CISwc from other diagnoses with specificity 86% and sensitivity 95% (area under the curve [AUC] 0.94). A K-FLC index <4.9 differentiated MOGAD from other diagnoses with specificity 63% and sensitivity 92% (AUC 0.78) and MOGAD from MS/CISwc with specificity 96% and sensitivity 92% (AUC 0.97). Among all patients, 93 (44%) had a K-FLC index <4.9: 24 of these (26%) had MOGAD and 5 (5.5%) MS/CISwc. Among the remaining patients with a K-FLC index ≥4.9 (n = 117), 2 (1.7%) had MOGAD (K-FLC index of 7.9 and 16.2) and 99 (85%) MS/CISwc. Among patients with normal MRI (n = 96), 73 (76%) had a K-FLC index <4.9: 22 of these (30%) had MOGAD, and none showed conversion to MS. Among the remaining patients with a K-FLC index ≥4.9 (n = 23), 2 (8.5%) had MOGAD and 7 (30.5%) showed conversion to MS. The K-FLC index did not differentiate NMOSD from other diagnoses and only moderately differentiated NMO from MS/CISwc (AUC 0.80).

DISCUSSION

The K-FLC index is an accessible biomarker to guide early diagnosis in patients with ION. The probability of MOGAD in patients with ION and a K-FLC index ≥4.9 is low even in case of normal brain/spinal cord MRI.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that for patients with ION, the K-FLC index can distinguish between MS/CISwc and MOGAD.

A case of MOGAD with rectal adenocarcinoma: Comorbidity or paraneoplastic neurological syndrome?

Background

Myelin-oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a rare autoimmune disease characterized primarily by central nervous system demyelination. We report a rare case of MOGAD coexisting with rectal adenocarcinoma.

Case report

A 59-year-old female presented with fever and bilateral lower limb weakness. MRI of the brain revealed abnormal signals in multiple regions of the cerebrum, brainstem, and spinal cord. Both serum and cerebrospinal fluid tested positive for MOG antibodies. The symptoms improved after steroid therapy. During hospitalization, colonoscopy and pathological examination revealed rectal cancer, which was subsequently treated surgically. After six months of follow-up, neither the tumor nor MOGAD recurred.

Conclusion

Paraneoplastic etiologies may also contribute to the development of MOGAD. To date, no cases of MOGAD associated with rectal cancer have been reported. It remains uncertain whether paraneoplastic neurologic syndrome (PNS) is involved in this patient.

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

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

Progression independent of relapse activity and relapse-associated worsening in seronegative NMOSD: an international cohort study

BACKGROUND

Previous studies have indicated that progression independent of relapse activity (PIRA) is uncommon in patients with aquaporin- 4 antibody-positive (AQP4-IgG) neuromyelitis optica spectrum disorder (NMOSD). However, the patterns of disability accumulation in seronegative NMOSD are unknown. This study aimed to evaluate the prevalence of PIRA and relapse-associated worsening (RAW) in seronegative NMOSD.

METHODS

We conducted a retrospective, multicentre cohort study of seronegative NMOSD patients from the MSBase registry. Inclusion criteria required at least three recorded expanded disability status scale (EDSS) scores: baseline, progression, and 6 months confirmed disability progression (CDP). For those with 6-month CDP, the presence or absence of relapse between baseline and progression determined the classification as RAW or PIRA, respectively. Descriptive statistics were employed to present the data.

RESULTS

This study included 93 patients, with a median follow-up duration of 5.0 years (Q1 2.8, Q3 8.4). The cohort predominantly consisted of female patients (77.4%), with a median age of onset of 33.9 years (Q1 26.1, Q3 41.2). PIRA was observed in 1 case (1.1%), whilst RAW was documented in 7 cases (7.5%).

CONCLUSION

This international cohort study confirms that CDP is uncommon in seronegative NMOSD. Given more than three quarters of CDP occur due to RAW, therapeutic strategies should focus primarily on preventing relapses.

Neuroimmunology and Sleep

The immune system and sleep are inextricably linked in both health and pathological conditions. Tightly regulated neuroimmune processes are critical for the physiological maintenance of healthy sleep. Reciprocally, sleep disturbances can detrimentally affect immune homeostasis and predispose to increased risk of autoimmune conditions, which themselves are bidirectionally associated with a higher risk of sleep disturbances. Autoimmune diseases of the central nervous system (CNS), particularly conditions that affect neuroanatomical regions involved in sleep homeostasis and nocturnal respiration, are associated with an increased risk sleep disorders that may impact diagnosis, clinical course, and management. This review summarizes the bidirectional relationship between sleep and immunity and highlights several exemplar autoimmune conditions of the CNS that include sleep disorders as a consequence or diagnostic feature of the disorder.

MOG35 - 55-induced EAE model of optic nerve inflammation compared to MS, MOGAD and NMOSD related subtypes of human optic neuritis

Optic neuritis (ON), or inflammation of the optic nerve, is a common presenting symptom of demyelinating neuroinflammatory conditions that result in significant, subacute vision loss. Given its association with visual impairment and varying extent of visual recovery, ON has been recognized as a significant health burden with a need for new therapeutic strategies to improve long-term visual outcomes. Among the resources utilized to study ON, animal models have emerged as powerful tools to examine the underlying pathophysiology and the effectiveness of proposed therapies. In the current review, we discuss the functional and structural phenotypes related to ON in currently used mouse models, and summarize how the pathophysiology and visual phenotype of the myelin oligodendrocyte glycoprotein 35-55 (MOG35 - 55) experimental autoimmune encephalomyelitis (EAE) mouse model recapitulates clinical features of multiple sclerosis (MS), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and neuromyelitis optica spectrum disorder (NMOSD). The location of ON and the amount of visual recovery in the EAE model most closely resembles MS and NMOSD. However, we propose that the MOG35 - 55-induced EAE model of ON is primarily a MOGAD model given its similarity in pathophysiology, spinal cord demyelination pattern, and the degree of vision loss, retinal nerve fiber layer (RNFL) swelling, and disc edema. Overall, the MOG35 - 55-induced EAE animal model demonstrates overlapping features of autoimmune demyelinating conditions and serves as a comprehensive tool to further our understanding of visual impairment in all three conditions.

The utility of serum neurofilament light chain in MOGAD: Current insights and future directions

BACKGROUND

Serum neurofilament light chain (sNfL) has become an increasingly established biomarker for monitoring in multiple sclerosis (MS). Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a demyelinating disorder distinct from MS in terms of pathophysiology and treatment options, also presenting with demyelinating attacks that can result in permanent disability. Given its unpredictable disease course, the need for biomarkers reflective of the risk for poor clinical recovery or relapsing course is pressing. The purpose of this review is to summarize the current knowledge on sNfL levels in people with MOGAD, assess their utility for clinical practice and gain insights for future research.

METHODS

Embase, MEDLINE, Scopus, and CINAHL databases were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Keywords used in the search included: (myelin oligodendrocyte glycoprotein OR MOG OR MOGAD) AND (neurofilament* OR neuro filament* OR NfL OR sNfL). This initial search generated 195 reports, 23 of which were original research articles investigating NfL levels in MOGAD patients, therefore meeting our inclusion criteria.

RESULTS

422 MOGAD patients were involved across all studies. Most studies revealed higher sNfL in MOGAD patients (n = 292) than in healthy controls (n = 3,172) with one study finding higher sNfL in MOGAD only during relapse. sNfL levels during attacks were similar when comparing MOGAD (n = 94) to MS (n = 256) and MOGAD (n = 149) to APQ4+ neuromyelitis optica spectrum disorder (APQ4+ NMOSD) (n = 214). MOGAD patients with brain lesions on magnetic resonance imaging (MRI) during a recent attack (n = 69 samples) had higher sNfL levels than patients without brain lesions (n = 78 samples). Median sNfL concentration was higher following clinical attacks (n = 69 samples) than in remission (n = 83 samples) in 3/5 studies. sNfL were higher at disease onset than subsequent attacks in 2 studies (n = 133 samples). Onset sNfL levels were not predictive of the likelihood of future relapse (relapsing: n = 15, monophasic: n = 18). A positive correlation was found between sNfL levels and attack severity assessed through various disability scales (n = 202), but not with the severity of acute or residual visual acuity (n = 45 eyes), or with residual retinal thickness among subjects with the optic neuritis (ON) phenotype (n = 11 eyes). The sGFAP/sNfL ratio showed utility in discriminating MOGAD from other autoimmune demyelinating diseases in two studies (MOGAD: n = 56, APQ4+ NMOSD: n = 66, MS: n = 31).

DISCUSSION

sNfL levels at presentation have limited utility in distinguishing MOGAD from other demyelinating disorders, but their combination with other biomarkers might improve their diagnostic utility. sNfL levels are higher in brain/spinal cord presentations than optic neuritis, correlating with clinical severity of these phenotypes but less so with the severity of visual outcome. Further studies should clarify the utility of sNfL as a biomarker for MOGAD, particularly in relation to long-term outcomes and imaging markers of central nervous system damage. Standardized sNfL testing parameters will improve study comparability and clinical application.

Brain Volume Measures in Adults with MOG-Antibody-Associated Disease: A Longitudinal Multicenter Study

Background/Objectives: Little is known about the impact of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) on brain atrophy. This multicenter longitudinal study compares brain MRI volumes and T2 lesion volume between MOGAD patients, relapsing-remitting MS (RRMS) patients and a healthy control (HC) group with brain MRI scans available from an online repository. Methods: In total, 16 adult MOGAD patients (9 F) were age- and sex-matched with 44 RRMS patients (17 F) recruited in Verona MS Center and 14 HC subjects. The availability of two brain MRI scans performed 18 ± 6 months apart was mandatory for each patient. Annual percentage brain volume change (PBVC/y), baseline global brain, white matter (WM), gray matter (GM) regional brain volumes and T2 lesion volume were compared between groups. Results: PBVC/y was lower in MOGAD than in RRMS patients (p = 0.014) and lower in HC subjects than in MS patients (p = 0.005). Overall, MOGAD showed higher mean global brain (p = 0.012) and WM volume (p = 0.024) but lower median T2 lesion volume at timepoint 1 (p < 0.001); T2 lesion volume increased over time in the RRMS (p < 0.001) but not in the MOGAD cohort (p = 0.262). Conclusions: The structural brain MRI features of MOGAD show higher global brain and WM volumes and lower brain volume loss over time compared to RRMS, suggesting different underlining pathogenetic mechanisms.

Myelin oligodendrocyte glycoprotein antibody-associated meningoencephalitis without cerebral parenchyma involvement on MRI: A single-centre paediatric cohort study

Since meningoencephalitis with prominent meningeal involvement was first described as a rare phenotype of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), sporadic cases have been reported. However, most of the reports were case reports and small sample cohorts. We conducted a retrospective analysis of paediatric patients with MOG antibody-associated meningoencephalitis without cerebral parenchyma involvement on imaging at Beijing Children's Hospital between 2017 and 2024. Upon reviewing the records of 320 MOG antibody-positive paediatric patients in our centre, we identified 18 (6%) patients (median age, 7.2 years; female, 10) with disease onset. The common clinical symptoms were fever (94%), headache (56%), seizure (44%) and vomiting (44%). Most patients had leukocytosis (78%) and elevated ESR and CRP levels (61%). Cerebrospinal fluid analysis revealed intracranial hypertension (28%), leukocytosis (100%) and elevated protein levels (33%). Negative cranial magnetic resonance images were observed in 4 patients, and meningeal enhancement was observed in 14 patients. Fourteen patients showed no improvement with antibiotic therapy but responded effectively to immunotherapy. After a median follow-up of 22 months, 4 (22%) of the 18 patients experienced relapse. At the time of the last follow-up, all patients had a good prognosis (mRS < 2). Conclusion: Meningoencephalitis without parenchymal involvement on MRI represents an underrecognized MOGAD phenotype. The incorporation of this entity into diagnostic criteria and the initiation of early immunotherapy could increase diagnostic sensitivity and reduce relapse risk in children.

Epidemiology of aquaporin-4 seropositive neuromyelitis optica spectrum disorder in the Alicante health area, Spain: A population-based study

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is an uncommon antibody-mediated inflammatory disease. The prevalence and incidence of NMOSD vary widely between geographical areas and ethnicities. To date, the only epidemiological study on NMOSD conducted in Spain has estimated an incidence rate of 0.63 per 1,000,000 person-years and a prevalence rate of 0.89 per 100,000 individuals in the general population. This population-based study aimed to estimate the incidence and prevalence of aquaporin-4 (AQP4)-seropositive NMOSD in the Alicante Health Area, Southeastern Spain, according to the 2015 International Panel for NMO Diagnosis (IPND) criteria and to investigate potential clinical and epidemiological differences that may exist in Spain in relation to NMOSD.

METHODS

In this retrospective population-based study, all patients diagnosed with AQP4-seropositive NMOSD according to the 2015 IPND criteria were identified using multiple sources. Seropositivity for AQP4 was confirmed in all cases using a cell-based assay. Two neurologists assessed the compliance with the 2015 IPND criteria. Clinical, imaging and laboratory data were obtained from medical records. The prevalence and incidence of AQP4-seropositive NMOSD were calculated using the Population Information System (SIP) data from the Alicante Health Area. The incidence rate covers January 2013-January 2023. The 95 % confidence intervals (CI) were calculated for the prevalence and incidence rates using Epidat software. Age-adjusted rates were calculated by the direct method of standardisation using Eurostat's European Standard Population in 2013 (ESP 2013) and the World Health Organization's World Standard Population expected in 2000-2025 (WHO 2000-2025) as reference populations.

RESULTS

Nine AQP4-seropositive NMOSD patients were identified in the Alicante Health Area. All patients except for one were Caucasian. The female-to-male ratio was 8:1, and the median age at onset was 39 years (range: 21-77 years). Most common clinical presentation was optic neuritis (five patients), followed by longitudinally extensive transverse myelitis (three patients) and postrema area syndrome (one patient). At the time of the study, all patients were being treated with chronic immunosuppressant treatment: tocilizumab (5/9 patients) and rituximab (4/9 patients). The overall prevalence rate was 3.11 (95 % CI: 1.42-5.91) per 100,000 individuals, while the overall annual incidence rate was 1.78 (95 % CI: 0.58-4.15) per million individuals. The age-standardised prevalence rate (using ESP 2013) was 3.09 (95 % CI: 0.62-8.77) per 100,000 individuals, and the annual incidence rate was 1.74 (95 % CI: 0.70-3.61) per million individuals. In addition, the age-standardised prevalence rate to the WHO 2000-2025 was 2.56 (95 % CI: 0.81-5.83) per 100,000 individuals, and the annual incidence rate was 1.66 (95 % CI: 0.54-3.89) per million individuals.

CONCLUSION

The crude and age-standardised prevalence rates of AQP4-seropositive NMOSD in our study were higher than those reported in other European studies. Our findings underscore that the epidemiology of AQP4-seropositive NMOSD is not uniform across Europe.

Serum anti-NMDA receptor antibodies are linked to memory impairment 12 months after stroke

Patients suffering from strokes are at increased risk of developing post-stroke dementia. Serum anti-NMDA receptor autoantibodies (NMDAR1-abs) have been associated with unfavorable post-stroke outcomes. However, their effect on specific cognitive domains remains unclear. We used data from the prospective multicenter DZNE-mechanisms after stroke (DEMDAS) cohort, and measured NMDAR1-abs in serum at baseline. Cognitive function was assessed with a comprehensive neuropsychological test battery at 6- and 12-months follow-up. We employed crude and stepwise confounder adjusted linear and logistic regression models as well as generalized estimating equation models (GEE) to determine the relevance of NMDAR1-abs seropositivity on cognitive function after stroke. 10.2% (58/569) DEMDAS patients were NMDAR1-abs seropositive (IgM:n = 44/IgA:n = 21/IgG:n = 2). Seropositivity was not associated with global cognitive impairment after stroke. However, NMDAR1-abs seropositive patients performed lower in the memory domain (βadjusted = -0.11; 95%CI = -0.57 to -0.03) and were at increased risk for memory impairment (ORadjusted = 3.8; 95%CI = 1.33-10.82) compared to seronegative patients, 12 months after stroke. Further, NMDAR1-abs were linked to memory impairment over time in GEE from 6- to 12-months follow-up (ORadjusted = 2.41; 95%CI = 1.05-5.49). Our data suggests that NMDAR1-abs contribute to memory dysfunction 1 year after stroke while not affecting other cognitive subdomains. Hence, antineuronal autoimmunity may be involved in distinct mechanisms of post-stroke memory impairment. Clinical trial name and registration number: The Determinants of Dementia After Stroke (DEMDAS; study identifier on clinical trials.gov: NCT01334749).

Cognitive and academic outcomes in children with myelin oligodendrocyte glycoprotein antibody-associated disease

AIM

To describe the impact of paediatric myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) on academic and cognitive outcomes.

METHOD

This was an observational, retrospective, and descriptive single-centre study, carried out on a paediatric case series of children with MOGAD.

RESULTS

A total of 51 patients were included (22 females); their median age was 8 years and the median follow-up duration was 31.1 months (interquartile range 23.5). The most frequent clinical presentation was acute disseminated encephalomyelitis (54.9%), followed by optic neuritis (35.5%). At the last follow-up, regardless of the clinical phenotype at disease onset, 39.5% of patients with MOGAD received academic and educational interventions (p < 0.05 compared to before disease onset), including academic accommodations (p < 0.05) or the need for a learning support assistant (p < 0.05). Ten patients were evaluated with the Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V). The overall IQ was calculated for six patients (mean = 92); two of these patients had an IQ lower than 85. No difference was found regarding prenatal and neonatal neurodevelopmental characteristics between this cohort and the general population.

INTERPRETATION

MOGAD was associated with a need for academic support; lower scores were found on the WISC-V. Patients with MOGAD should receive cognitive and academic assessments to inform educational planning and support academic success.

Optic Neuritis

OBJECTIVE

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

LATEST DEVELOPMENTS

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

ESSENTIAL POINTS

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

A single-center retrospective series of OCT and MRI findings in pediatric MOGAD optic neuritis patients

BACKGROUND

Whether optical computed tomography (OCT) and magnetic resonance imaging (MRI) findings are associated with final visual acuity in children with myelin oligodendrocyte glycoprotein antibody disease (MOGAD) optic neuritis is unclear.

METHODS

We retrospectively reviewed the charts of pediatric patients with MOGAD optic neuritis seen at St. Louis Children's Hospital/Barnes Jewish Hospital since 2016.

RESULTS

In the 12 patients in this study, presenting visual acuity was worse in the optic neuritis-affected eyes but significantly improved from presentation to follow-up, such that, at last follow-up, there was no longer a statistical difference between the affected and unaffected eyes. The number of affected eyes with nerve enhancement and the amount of optic nerve affected, as well as thickness of the retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), and macula, decreased from presentation to follow-up. Ultimately, none of these variables were associated with final visual acuity.

CONCLUSION

In this cohort, pediatric MOGAD optic neuritis patients had positive visual outcomes despite significant RNFL thinning and involvement of the optic nerve on MRI, leading to a lack of correlation between follow-up visual acuity and OCT and MRI measures of disease severity, respectively.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

MOGAD optic neuritis after mild head/orbital trauma in six children

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a potential cause of optic neuritis (ON). Its triggers and etiologies are not completely understood. We describe a novel clinical observation in six young patients with MOGAD-ON in the setting of strikingly parallel histories of mild head/orbital trauma. This is a single-center retrospective case series of six young patients and age-matched isolated MOGAD-ON controls. We present data both individually (de-identified, only the six trauma-associated cases) and in aggregate. Averages are presented as the arithmetic mean +/- SEM. 6/27 patients with MOGAD-ON, (3/6 female), between 8 and 18 years old presented with ON 5.5 days after mild head trauma. Four patients developed ON ipsilateral to their unilateral head trauma while two developed bilateral ON following midline head trauma. All patients tested positive for serum anti-MOG antibodies upon ON workup. They all received intravenous corticosteroids with rapid improvement in symptoms (5.5 weeks to full visual recovery) and none have since relapsed. No other patients with MOGAD-ON experienced preceding head trauma, and all patients in the control group were asked about trauma upon assessment of the history. Head trauma may serve as an inciting event in the presentation and diagnosis of MOGAD-ON. This novel observation provides a potential pathophysiologic mechanism independent of infectious triggers, although we cannot determine if these patients were already predisposed towards MOGAD-ON.

Radiological features in pediatric myelin oligodendrocyte glycoprotein antibody-associated disease-diagnostic criteria and lesion dynamics

The spectrum of acquired pediatric demyelinating syndromes has been expanding over the past few years, to include myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), as a distinct neuroimmune entity, in addition to pediatric-onset multiple sclerosis (POMS) and aquaporin 4-IgG-seropositive neuromyelitis optica spectrum disorder (AQP4+NMOSD). The 2023 MOGAD diagnostic criteria require supporting clinical or magnetic resonance imaging (MRI) features in patients with low positive myelin oligodendrocyte glycoprotein IgG titers or when the titers are not available, highlighting the diagnostic role of imaging in MOGAD. In this review, we summarize the key diagnostic features in MOGAD, in comparison to POMS and AQP4+NMOSD. We describe the lesion dynamics both during attack and over time. Finally, we propose a guideline on timing of imaging in clinical practice.

Uncovering alternative diagnoses in patients with clinical syndromes suggestive of multiple sclerosis: A transversal study from the prospective Barcelona CIS cohort

BACKGROUND

It is essential to exclude alternative diagnoses to diagnose multiple sclerosis (MS). However, detailed descriptions of alternative diagnoses in patients with suspected MS presenting with clinically isolated syndrome (CIS) are limited.

OBJECTIVES

To describe alternative diagnoses in patients presenting with CIS suggestive of MS.

METHODS

We conducted a descriptive analysis of patients from the Barcelona CIS cohort including subjects under 50 years of age with a CIS suggestive of MS but later diagnosed with conditions other than MS. We collected clinical, biological, and radiological data, and described the alternative etiologies identified.

RESULTS

Among 1468 patients in the Barcelona CIS cohort, 100 (6.8%) were diagnosed with an alternative condition. The most common neurological syndrome was optic neuritis (43.0%). Four patients (4.0%) had inflammatory-demyelinating lesions in at least two typical MS topographies on baseline magnetic resonance imaging (MRI), and 2 (2.0%) met the 2017 McDonald MS criteria. The most common etiologies were immune-mediated diseases (42.0%), especially MOGAD, followed by functional neurological disorders (15.0%) and vascular disease (10.0%).

CONCLUSION

The range of alternative diagnoses encountered during the MS diagnostic process highlights the need to rule out better explanations than MS. However, current MS diagnostic criteria effectively identify patients without MS in this context.

MOG antibody non-P42 epitope is associated with a higher risk of relapse in paediatric MOGAD

BACKGROUND

Biomarkers for predicting myelin oligodendrocyte glycoprotein antibody (Ab)-associated disease (MOGAD) clinical course are still missing. Binding capacity to a mutant MOG protein variant (MOG-P42S; non-P42) was shown to correlate with an increased relapse risk in adult patients.The objective of our study was to assess the frequency of binding to the non-P42 MOG variant in a cohort of paediatric MOGAD and to investigate its association with specific clinical profiles and disease course.

METHODS

We included children with MOG-Ab seropositive samples collected after their first demyelinating episode from five different centres. We performed live cell-based assays with native full-length MOG (MOG-FL) and mutant MOG-P42S and correlated the results with clinical data.

RESULTS

Of the 81 MOG-FL identified patients serum, 40 bound the non-P42 MOG. Non-P42 patients exhibited an earlier median age of onset (p=0.002). Phenotype distribution was different between groups (p=0.001), with non-P42 patients predominantly exhibiting acute disseminated encephalomyelitis phenotype. Notably, the non-P42 group was associated with a higher relapse rate (relative rate: 2.6 (95% CI 1.1 to 6.2), p=0.03), adjusted for clinical phenotype.

CONCLUSION

Non-P42 is a promising biomarker for predicting relapse in paediatric MOGAD patients.

Predictors of relapse risk and treatment response in AQP4-IgG positive and seronegative NMOSD: A multicentre study

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) can be categorised into aquaporin-4 antibody (AQP4-IgG) NMOSD or seronegative NMOSD. While our knowledge of AQP4-IgG NMOSD has evolved significantly in the past decade, seronegative NMOSD remains less understood. This study aimed to evaluate the predictors of relapses and treatment responses in AQP4-IgG NMOSD and seronegative NMOSD.

METHODS

This was a multicentre, international, retrospective cohort study using the MSBase registry. Recurrent relapse risk was assessed using an Andersen-Gill model and risk of first relapse was evaluated using a Cox proportional hazards model. Covariates that putatively influence relapse risk included demographic factors, clinical characteristics and immunosuppressive therapies; the latter was assessed as a time-varying covariate.

RESULTS

A total of 398 patients (246 AQP4-IgG NMOSD and 152 seronegative NMOSD) were included. The AQP4-IgG NMOSD and seronegative NMOSD patients did not significantly differ by age at disease onset, ethnicity or annualised relapse rate. Both low-efficacy and high-efficacy immunosuppressive therapies were associated with significant reductions in recurrent relapse risk, with notably greater protection conferred by high-efficacy therapies in both AQP4-IgG NMOSD (HR 0.27, 95% CI 0.15 to 0.49, p<0.001) and seronegative NMOSD (HR 0.21, 95% CI 0.08 to 0.51, p<0.001). Longer disease duration (HR 0.97, 95% CI 0.95 to 0.99, p<0.001) and male sex (HR 0.52, 95% CI 0.34 to 0.84, p=0.007) were additional protective variables in reducing the recurrent relapse risk for the AQP4-IgG NMOSD group.

CONCLUSION

Although further studies are needed to improve our understanding of seronegative NMOSD, our findings underscore the importance of aggressive treatment with high-efficacy immunotherapies in both NMOSD subtypes, regardless of serostatus.

Comparison of vision-related quality of life in NMOSD and MOGAD

BACKGROUND

Aquaporin-4 antibody positive neuromyelitis spectrum disorder (AQP4+ NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD) are both associated with vision loss due to optic neuritis (ON), although evidence suggests more severe structural damage in NMOSD. The validated National Eye Institute Visual Function Questionnaire (VFQ) may be used to evaluate patients' perceptions of how vision impairment affects their lives.

OBJECTIVE

To compare vision-related quality of life in AQP4+ NMOSD and MOGAD using the NEI-VFQ.

METHODS

Participants with AQP4+ NMOSD and MOGAD, 18 years of age and older, were enrolled through the Canadian NMOSD and other atypical demyelinating diseases cohort study (CANOPTICS) at six Canadian centers and consented to enter the patient-reported outcomes sub-study. Participants completed the VFQ at study entry. We compared composite VFQ scores and subscale scores in all participants with NMOSD and MOGAD, those with a history of any ON, and those with a history of bilateral simultaneous ON. We used a multivariable linear regression model to evaluate the association of VFQ composite score with disease type (NMOSD versus MOGAD), age, sex at birth, disease duration, history of unilateral ON, history of bilateral ON, and visual functional system score (FSS).

RESULTS

There were 58 NMOSD participants, 49 (84.5 %) female, mean (SD) age 48.6 (14.8) years, and 42 MOGAD participants, 27 (64.3 %) female, mean (SD) age 45.2(15.1) years. Thirty-five (60.3 %) participants with NMOSD had a history of any ON and 11(19.0 %) of bilateral ON. For MOGAD, 30 (71.4 %) participants had a history of any ON and 14 (33.3 %) of bilateral ON. Mean (SD) VFQ composite scores were 82.2 (17.9) in NMOSD and 83.7 (17.6) in MOGAD for the full cohort; 75.0 (19.9) in NMOSD and 80.4 (18.7) in MOGAD for those with any history of ON; and 70.2 (25.6) in NMOSD and 74.9 (21.8) in MOGAD for bilateral ON. Composite scores did not differ significantly between participants with NMOSD and MOGAD in the full cohort or ON sub-groups. However, history of bilateral ON (β=-13.2, p = 0.0008) and higher visual FSS (β=-4.9, p < 0.0001) were associated with lower VFQ composite scores.

CONCLUSION

In this Canadian multi-center cohort, vision-related quality of life was impaired in both NMOSD and MOGAD, without significant differences observed in scores. Vision-related quality of life assessment offers unique insights into the functional impact of vision loss, and should be considered as an outcome measure to evaluate visual disability in NMOSD and MOGAD in addition to visual acuity.

Visual evoked potential in myelin oligodendrocyte glycoprotein antibody-associated disease

The visual evoked potential (VEP) patterns of optic neuritis are known to often differ between multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) but have been less reported in myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). This study aimed to characterize the VEP pattern in MOGAD and evaluate its utility in distinguishing MOGAD from MS and NMOSD. We retrospectively reviewed the clinical manifestations and VEP findings in patients with MS (n = 29), NMOSD (n = 14), and MOGAD (n = 10). In eyes with acute visual impairment, VEP responses were detectable in 100 % of eyes with MOGAD, a striking difference from MS (72.7 %) and NMOSD (57.1 %). In addition, VEP abnormalities in eyes without acute visual impairment were rare in MOGAD (23.1 %) compared to MS (55.3 %) and NMOSD (42.9 %). Our results indicated that subclinical VEP abnormalities or undetectable VEP responses were less common in patients with MOGAD compared to patients with MS and NMOSD. VEP testing demonstrates potential diagnostic utility in distinguishing among these conditions.

Comparison of clinical features of aquaporin-4 positive neuromyelitis optica spectrum disorder (NMOSD), myelin oligodendrocyte glycoprotein associated disorder (MOGAD), and double seronegative NMOSD - A single center experience

This retrospective study investigates Aquaporin-4 Antibody Positive Neuromyelitis Optica Spectrum Disorder (NMOSD), Myelin Oligodendrocyte Glycoprotein Associated Disorder (MOGAD), and Seronegative NMOSD at a tertiary care university hospital, over a 13 year period (November 2010 to November 2023) involving 78 patients. It distinguishes between the clinical and radiological features of AQP4 + NMOSD (41 patients, 52.5 %), MOGAD (22 patients, 28.2 %), and Seronegative NMOSD (15 patients, 19.3 %). A significant female majority was noted in AQP4+ NMOSD (90.2 %) compared to MOGAD (45.5 %) and Seronegative NMOSD (66.7 %). Age of disease onset and annualized relapse rates were similar across groups. Myelitis was a common initial symptom in AQP4+ NMOSD (48.8 %) and Seronegative NMOSD (40 %), but less so in MOGAD (18.2 %). Optic neuritis was more frequent in MOGAD (68.2 %) and Seronegative NMOSD (53.3 %) than AQP4+ NMOSD (31.7 %). Relapsing disease was less observed in MOGAD (57.1 %) compared to the other groups. Time to the first relapse varied: 12 months for Seronegative NMOSD, 18 months for AQP4+ NMOSD, and 7 months for MOGAD. A higher incidence of autoimmune disorders was found in AQP4+ NMOSD (36.6 %) versus MOGAD (9.5 %). This study delineates a pronounced female and concurrent autoimmune disorder predominance in AQP4+ NMOSD compared to seronegative NMOSD and MOGAD.

Clinico-investigational profile, relapse predictors and outcomes of pediatric patients with anti-myelin oligodendrocyte associated disorders: An experience from tertiary centre

BACKGROUND

The data on relapse and outcome predictors in pediatric anti-Myelin oligodendrocyte antibody associated diseases (MOGAD) is poorly delineated in the literature.

METHODS

We performed a retrospective study of the clinico-investigational profile of pediatric patients (age<18 years) who met the international diagnostic criteria for MOGAD, 2023 and assessed the predictors for clinical relapse and equated the trajectory of outcomes over a long-term follow-up.

RESULTS

We recruited 46 children (males=24, 52.2 %), with a median age at onset 11(8 to 16) years and a median duration of 15 (IQR 6-45) days. The core demyelinating events observed were optic neuritis (n = 19, 41.3 %), acute disseminating encephalomyelitis (n = 13, 28.3 %), transverse myelitis (n = 10, 21.7 %), cerebral deficits (n = 3, 6.5 %), brainstem/cerebellar syndrome (n = 2, 4.3 %), cerebral cortical encephalitis (n = 2, 4.3 %) and atypical presentations (n = 1, 2.2 %). Prevalence of ADEM was significantly higher among children <10 years (p = 0.046). At a median follow-up of 28 months, ON was significantly associated with relapse, with an odds ratio (OR) of 5.175 (95 % CI 1.286-20.824, p = 0.021), unlike other core demyelinating events. In 11 cases (23.9 %) referral diagnosis was not MOGAD. Neither the degree of serum anti-MOG antibody positivity [strong vs weak: OR 1.506 (0.407 to 5.578), p = 0.480] nor its persistence [OR 0.955 (0.201 to 4.538), p = 0.953] were identified to be relapse predictors. There was a significant improvement in modified Rankin scale (mRS) scores between presentation, intermediate and at last follow-up (p < 0.001).

CONCLUSIONS

The study highlights the predictors for relapse, and presents a follow-up data of >2 years on pediatric MOGAD. It reveals optic neuritis as a risk factor for relapse. The study emphasises the importance of a broad range of antibody testing including anti-MOG in patients with suspected autoimmune encephalitis.

Smoking status and vascular risk factors as predictors of disability in AQP4-NMOSD and MOGAD

BACKGROUND

Smoking and vascular risk factors (VRFs) are reported to have adverse effects in multiple sclerosis but data are limited in aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD). This study aimed to measure their impact on disability.

METHODS

Smoking status was defined as never, past or current smokers and VRF comprised of ⩾1: hypertension, dyslipidemia, high body mass index or diabetes. Logistic regression models were fitted to predict their influence on recovery from onset attack and first optic neuritis (ON) attack.

RESULTS

A total of 442 patients were included. Current MOGAD smokers had a higher risk of disability from onset attack and first ON attack than never smokers (odds ratio (OR) 2.9, 95% confidence interval (CI) 1.3-6.9; OR 3.3, 95% CI 1.4-7.8). VRF in MOGAD was not predictive of disability. Current AQP4-NMOSD smokers and VRFs had a higher risk of residual disability from onset attacks (OR 7.5, 95% CI 2.1-27.7; OR 1.9, 95% CI 1.0-3.4). VRF was associated with higher risk of visual disability (OR 2.6, 95% CI 1.08-6.46) while smoking status was not.

CONCLUSIONS

Current smoking status detrimentally influenced onset attack recovery in AQP4-NMOSD and MOGAD patients, including visual recovery in MOGAD. Non-smoking VRFs influenced clinical and visual outcomes in AQP4-NMOSD.

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

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

Clinical characteristics of children with anti-N-methyl-D-aspartate receptor encephalitis with and without anti-myelin oligodendrocyte glycoprotein antibody

To analyze the clinical characteristics of an overlapping syndrome, MNOS, of anti-myelin oligodendrocyte glycoprotein antibody (MOG-Ab) coexisting with anti-N-methyl-D-aspartate receptor encephalitis (NMDARE) in children. We included patients with NMDARE at Children's Hospital of Chongqing Medical University between 2018 and 2022 and conducted a comparison between NMDARE with and without MOG-Ab. Among 163 patients with NMDARE, 15 individuals tested positive for MOG-Ab. The median age of MNOS was 11 years (IQR 8-13). Furthermore, 10 out of 15 were female. More than half of MNOS experienced a prior history of encephalitis or demyelinating disorders. Among ten patients with low MOG-Ab titers, two met the diagnostic criteria for MOGAD. All five patients with high MOG-Ab titers satisfied the criteria for MOGAD. A total of seven patients diagnosed with MOGAD presented with acute disseminated encephalomyelitis. The proportion of prodromal symptoms and brain lesions, the neutrophil counts, and the frequency of mycophenolate mofetil administration were significantly higher in MNOS compared to NMDARE patients without MOG-Ab (p < 0.05). The outcomes of MNOS were favorable and comparable to those observed in NMDARE. Nevertheless, MNOS demonstrated a higher tendency to relapse, with rates of 60.0% compared to 3.1% (p < 0.001).

CONCLUSION

Pediatric MNOS exhibited a high prevalence among females, particularly those with a prior history of MOGAD or encephalitis. MNOS had a favorable prognosis but with a high relapse rate. Coexisting MOG-Ab in pediatric MNOS may be pathogenic or a bystander, potentially correlating with antibody titers.

WHAT IS KNOWN

• Pediatric anti-N-methyl-D-aspartate receptor encephalitis (NMDARE) coexisting with anti-myelin oligodendrocyte glycoprotein antibody (MOG-Ab) generally has a favorable prognosis, albeit with a tendency to relapse. • Pediatric NMDARE coexisting with MOG-Ab may exhibit imaging features indicative of demyelination.

WHAT IS NEW

• Pediatric patients of MOG-Ab coexisting with NMDARE overlapping syndrome (MNOS) were predominantly observed in females, particularly those with a history of MOG-Ab-associated disorder (MOGAD) or encephalitis. • Compared with NMDARE patients, pediatric MNOS patients had higher neutrophil counts and more frequently exhibited abnormal MRI findings in the basal ganglia, insular lobe, temporal lobe, thalamus, and cerebellum.

Limited early IVIG for the treatment of pediatric myelin oligodendrocyte glycoprotein antibody-associated disease

BACKGROUND AND OBJECTIVES

This study aimed to evaluate whether a 6-month (limited) course of early IVIG is an effective strategy for relapse prevention in children with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) versus only acute therapies or other early immunotherapies.

METHODS

This was a retrospective multicenter observational study of pediatric MOGAD patients from the US Network of Pediatric Multiple Sclerosis Centers with disease onset between October 1996 and December 2022. Controls were matched to limited early IVIG subjects using a 3:1 ratio. Hazard ratios of time to relapse and rate ratios of annualized relapse rate were calculated. The cumulative probability of remaining relapse-free was evaluated with the Kaplan-Meier method.

RESULTS

We identified 130 unique control subjects treated before second attack with acute treatments only used in matching, 18 subjects treated with limited early IVIG, and 23 subjects treated with other early immunotherapy. The time to relapse was not different between either the limited early IVIG group and control group (HR 0.60 [0.22, 1.66], p = 0.32) or other early immunotherapy group (HR 0.98 [0.27, 3.6], p = 0.98). The limited early IVIG group showed a lower annualized relapse rate, although not statistically significant (RR 0.44 [0.17, 1.14], p = 0.09) compared with controls and a similar annualized relapse rate compared with the other early immunotherapy group (RR 0.56 [0.19, 1.69], p = 0.30).

DISCUSSION

Although underpowered, our results suggest that the use of a limited, 6-month course of early IVIG may reduce the risk of multiphasic disease in pediatric MOGAD.

Tumefactive demyelinating lesions in children

Tumefactive lesions (TDL) are larger than 2 cm in diameter on T2-weighted brain MRI. They are distinguished from other types of demyelinating lesions by their size and degree of perilesional edema and/or rim enhancement, which can make diagnosis challenging.

AIM

To study the clinical and radiological features, follow-up and final diagnosis of patients presenting with TDL.

METHOD

Medical records of children seen at the Pediatric neurology and radiology department between 1992 and 2017 were reviewed. 15 patients younger than 18 years of age who had at least one TDL on their first magnetic resonance imaging (MRI) were included. Clinical and radiological features and evolution of imaging findings were studied.

RESULTS

First, all patients were admitted acutely with a polysymptomatic presentations (86,6 %) mainly affecting the motor system (92,8 %). The largest diagnostic group was MS (n = 10, 66,6 %) with 9 out of 10 individual's diagnosed during follow up. At least one new clinical or radiological relapse was observed in 12 patients with a mean occurrence of 9 and 14 months respectively. All cases who developed a radiological relapse and most (n: 9, 75 %) of those who experienced a clinical relapse were diagnosed with MS and all had new lesions at the time of diagnosis. All children with MS had positive OCBs. X children were diagnosed with xxxxx Most TDLs (21/24, 87,5 %) were localized in the supratentorial area. TDL + other demyelinating lesions were observed in most 12/15 (80 %) patients and the size of TDL was between 2 and 4 cm (20/24, 83.3 %). All patients with MS, whether they had a single TDL or multiple TDLs, had accompanying small demyelinating lesions. On follow-up all TDLs became smaller (14/15, 93,3 %) or resolved (n = 1).

CONCLUSION

The non-infiltratind pattern, presence of multiple small demyelinating lesions and CSF oligoclonal band positivity may suggest MS, which is one of the most common causes. However, for a definitive diagnosis, patients should continue to be monitored with radiological imaging even in the absence of clinical relapses.

The nomogram model predicts relapse risk in myelin oligodendrocyte glycoprotein antibody-associated disease: a single-center study

Background

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an autoimmune disorder of the central nervous system, characterized by seropositive MOG antibodies. MOGAD can present with a monophasic or relapsing course, where repeated relapses may lead to a worse prognosis and increased disability. Currently, little is known about the risk factors for predicting MOGAD relapse in a short period, and few established prediction models exist, posing a challenge to timely and personalized clinical diagnosis and treatment.

Methods

From April 2018 to December 2023, we enrolled 88 patients diagnosed with MOGAD at the First Hospital of Shanxi Medical University and collected basic clinical data. The data were randomly divided into a training cohort (80%) and a validation cohort (20%). Univariate logistic regression, least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression were used to identify independent risk factors for 1-year relapse. A prediction model was constructed, and a nomogram was developed. The receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate and internally validate model performance.

Results

Among 88 MOGAD patients, 29 relapsed within 1 year of onset (33%). A total of 4 independent risk factors for predicting relapse were identified: female sex (P=0.040), cortical encephalitis phenotype (P=0.032), serum MOG antibody titer ≥1:32 (P=0.007), and immunosuppressive therapy after the first onset (P= 0.045). The area under curve (AUC) value of the nomogram prediction model constructed with these four factors was 0.866 in the training cohort, and 0.864 in the validation cohort. The cutoff value of the total nomogram score was 140 points, distinguishing the low relapse risk group from the high relapse risk group (P < 0.001). The calibration curve demonstrated high consistency in prediction, and the DCA showed excellent net benefit in the prediction model. Tested by ROC curve, calibration curve, and DCA, the nomogram model also demonstrates significant value in predicting MOGAD relapse within 2 years.

Conclusion

The nomogram model we developed can help accurately predict the relapse risk of MOGAD patients within one year of onset and assist clinicians in making treatment decisions to reduce the chance of relapse.

Progressive Myelitis in a 63-Year-Old Woman: A Case Report From the National Multiple Sclerosis Society Case Conference Proceedings

We present a case of myelitis in a 63-year-old woman with breast adenocarcinoma treated with pembrolizumab. MRI showed multiple T2-hyperintense lesions throughout the spinal cord, and CSF demonstrated lymphocytic pleocytosis. We discuss the differential diagnosis of myelitis in the setting of cancer and immune checkpoint inhibitors.

Pathogenic TNFRSF13B Variant in an Adult Japanese Patient with Common Variable Immunodeficiency

Common variable immunodeficiency (CVID) is a primary B cell immunodeficiency disorder. Symptoms do not develop immediately after birth, and patients are often diagnosed in childhood and adulthood. These patients often develop autoimmune diseases and malignant tumors. We herein report a 50-year-old woman with severe hypogammaglobulinemia and recurrent respiratory tract infections who was diagnosed with CVID. Target sequencing showed a TNFRSF13B heterozygous frameshift variant. The patient had many comorbidities, probably caused by a CVID-induced immune imbalance. Physicians who treat adult patients are often unaware of CVID. CVID should be recognized as a differential diagnosis in hypogammaglobulinemia and recurrent infections.

Associations between fronto-limbic white matter connections and internalizing symptoms in pediatric demyelinating disease

INTRODUCTION

Children with neuroinflammatory disorders, such as multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein-associated disorder (MOGAD), have high rates of anxiety and depression. These symptoms may be linked to disruptions in fronto-limbic white matter (WM) tracts, including the cingulum bundle (CB), inferior fronto-occipital fasciculus (IFOF), and uncinate fasciculus (UF), which support emotional regulation.

METHODS

We studied 33 children with neuroinflammatory disorders and 28 healthy controls. Diffusion tensor imaging and white matter tract integrity maps were generated, focusing on WM tracts of interest (CB, IFOF, UF) and a control tract (acoustic radiation). We examined differences in WM microstructure and internalizing symptoms between high and low symptom groups.

RESULTS

Participants with MS (40%), MOGAD (28%), and NMOSD (25%) reported high levels of internalizing symptoms. MOGAD participants showed lower axonal water fraction compared to MS and controls. Both MS and MOGAD groups exhibited reduced intra-axonal diffusivity and increased extra-axonal diffusivity, indicating demyelination and axonal changes. No significant differences were found between high and low internalizing groups, but higher relapse rates were linked to less WM disruption in those with high internalizing symptoms.

LIMITATIONS

The cross-sectional design limits causal interpretations, and medical covariates may affect WM structure.

CONCLUSION

Neuroinflammatory disorders are linked to fronto-limbic WM changes and high internalizing symptoms. Relapse may influence WM structure and psychological resilience in this population.

Progressive unilateral tremor associated with large confluent perirolandic juxtacortical lesions in multiple sclerosis

BACKGROUND

Multiple sclerosis (MS)-related tremor is classically attributed to infratentorial lesions.

OBJECTIVE

To characterize unilateral tremor associated with perirolandic lesions in MS.

METHODS

This retrospective study included Mayo Clinic patients diagnosed with MS who had: 1) Progressive unilateral tremor; and 2) Contralateral perirolandic juxtacortical T2-lesion. Medical records, neuroimaging and movement laboratory studies were evaluated.

RESULTS

Of 12 patients, 8 were female. Median age of tremor onset was 36.5 years (range, 23-49), with diagnosis of MS a median of 101 months (range, 5-238) after. Tremor was the first MS symptom in 10 and all had progression. Most had tremors (10/12) in the 4.5 - 7 Hz range, while 2 had Holmes tremors in 3 - 5 Hz range. The perirolandic lesions were often large and confluent. All 3 with acute/subacute MRIs (within 4 months of onset) had enhancement. There was lesional atrophy in 6/11 with follow-up imaging available. Detailed treatment outcomes are described.

CONCLUSION

Progressive unilateral tremor with contralateral perirolandic lesion is a novel phenotype of progressive MS and the pathogenesis may reflect disruption of cerebello-thalamo-cortical circuitry.

Real-world clinical experience with serum MOG and AQP4 antibody testing by live versus fixed cell-based assay

OBJECTIVE

To assess the real-world performance of a live (LCBA) versus a fixed (FCBA) cell-based assay for the detection of serum antibodies directed against myelin oligodendrocyte glycoprotein (MOG-IgG) and aquaporin-4 (AQP4-IgG).

METHODS

This was a retrospective study of patients evaluated at a single tertiary academic referral center, with serum testing performed clinically for AQP4-IgG and/or MOG-IgG by FCBA and LCBA on the same day. Additionally, frozen banked sera from the same day for patients tested only by one assay were retrieved and tested by the other assay. FCBA was performed by the Johns Hopkins Immunology Laboratory using Euroimmun kits with detection by indirect immunofluorescence (FCBA-IF), whereas LCBA was performed by the Mayo Clinic Neuroimmunology Laboratory with detection by flow cytometry (LCBA-FACS).

RESULTS

Of 594 specimens with paired MOG-IgG testing, 500 were negative by both assays, 33 were positive by both assays, 56 were positive exclusively by LCBA-FACS, and 5 were only positive by FCBA-IF. Overall, MOG-IgG LCBA-FACS exhibited 95.1% sensitivity and 97.7% specificity, whereas MOG-IgG FCBA-IF had 45.7% sensitivity and 99.8% specificity. Of 577 specimens with paired AQP4-IgG testing, 503 were negative by both assays, 51 were positive by both assays, 21 were positive exclusively by LCBA-FACS, and 2 were only positive by FCBA-IF. Overall, AQP4-IgG LCBA-FACS exhibited 97.3% sensitivity and 100% specificity, whereas AQP4-IgG FCBA-IF had 71.6% sensitivity and 100% specificity.

INTERPRETATION

LCBA-FACS for both MOG-IgG and AQP4-IgG had markedly better sensitivity than FCBA-IF, with similar specificity. The use of FCBA-IF may result in underrecognition of both MOG antibody-associated disease (MOGAD) and AQP4-IgG seropositive neuromyelitis optica spectrum disorder (NMOSD).

Pediatric cerebrospinal fluid immune profiling distinguishes pediatric-onset multiple sclerosis from other pediatric-onset acute neurological disorders

The cerebrospinal fluid (CSF) provides a unique glimpse into the central nervous system (CNS) compartment and offers insights into immune processes associated with both healthy immune surveillance as well as inflammatory disorders of the CNS. The latter include demyelinating disorders, such as multiple sclerosis (MS) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), that warrant different therapeutic approaches yet are not always straightforward to distinguish on clinical and imaging grounds alone. Here, we establish a comprehensive phenotypic landscape of the pediatric CSF immune compartment across a range of non-inflammatory and inflammatory neurological disorders, with a focus on better elucidating CNS-associated immune mechanisms potentially involved in, and discriminating between, pediatric-onset MS (MS) and other pediatric-onset suspected neuroimmune disorders, including MOGAD. We find that CSF from pediatric patients with non-inflammatory neurological disorders is primarily composed of non-activated CD4+ T cells, with few if any B cells present. CSF from pediatric patients with acquired inflammatory demyelinating disorders is characterized by increased numbers of B cells compared to CSF of both patients with other inflammatory or non-inflammatory conditions. Certain features, including particular increased frequencies of antibody-secreting cells (ASCs) and decreased frequencies of CD14+ myeloid cells, distinguish MS from MOGAD and other acquired inflammatory demyelinating disorders.

Retrospective, descriptive study of acute myelitis in French Guyana

BACKGROUND

Acute myelitis is a neurological entity, often posing the problem of etiology. The two main causes are infectious or autoimmune. French Guyana is a region of the world where infectious etiologies are multiple, in particular human immunodeficiency virus infection, and autoimmune diseases appear to be emerging. The aim of our study was firstly to determine the proportion of each etiology of acute myelitis in French Guyana, and secondly to describe the clinical, paraclinical and epidemiological characteristics of autoimmune myelitis in French Guyana, with particular reference to neuromyelitis optica spectrum disorder (NMOSD).

METHODS

This retrospective, observational study included all patients who presented with acute myelitis between January 2015 and August 2023 at Cayenne Hospital Center. Each patient's chart was reviewed and patients were classified according to etiology. Demographic and clinical data were collected, as well as blood, lumbar puncture, and cerebral and spinal cord magnetic resonance imaging results.

RESULTS

Of the 40 patients included, immune etiology was found in 74%, including 49% with NMOSD (37% with positive anti-aquaporin-4 antibodies) compared with three patients with infectious etiology. There was no statistically significant difference in complementary examinations between immune and infectious etiologies. The prevalence of NMOSD in French Guyana was estimated at 8/100,000 (6/100,000 for patients with positive anti-aquaporin-4 antibodies). No significant difference in the geographic distribution of patients with NMOSD in French Guyana was demonstrated.

CONCLUSIONS

Our results show a high proportion of autoimmune etiology of acute myelitis in French Guyana, and more particularly of NMOSD. There is a high prevalence of NMOSD, the second highest in the world after the French West Indies. Given this high proportion of autoimmune myelitis, several hypotheses can be put forward, with genetic and environmental factors in the foreground. For patients with acute myelitis in French Guyana, an immune cause is the most likely. It is therefore important to think about this and look for NMOSD in particular, without ignoring an infectious etiology.

Conformational Antibodies to Proteolipid Protein-1 and Its Peripheral Isoform DM20 in Patients With CNS Autoimmune Demyelinating Disorders

BACKGROUND AND OBJECTIVES

Antibodies to proteolipid protein-1 (PLP1-IgG), a major central myelin protein also expressed in the peripheral nervous system (PNS) as the isoform DM20, have been previously identified mostly in patients with multiple sclerosis (MS), with unclear clinical implications. However, most studies relied on nonconformational immunoassays and included few patients with non-MS CNS autoimmune demyelinating disorders (ADDs). We aimed to investigate conformational PLP1-IgG in the whole ADD spectrum.

METHODS

We devised a new live cell-based assay (CBA) for PLP1-IgG and used it to test 2 cohorts (retrospective exploratory, n = 284; prospective validation, n = 824) of patients with ADDs and controls (n = 177). Patients were classified as MS, neuromyelitis optica spectrum disorders (NMOSDs), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and other ADDs. PLP1-IgG-positive samples were tested for IgG subclasses, DM20-IgG, and on rat brain tissue-based assay (TBA). Complement-dependent cytotoxicity (CDC) was assessed on a live CBA and antigen specificity and conformational binding through immunoadsorption/colocalization/fixation experiments.

RESULTS

PLP1-IgG were found in 0 of 177 controls and 42 of 1104 patients with ADDs mainly diagnosed as other ADDs (19/42) with frequent myelitis/encephalomyelitis (14/19) and coexisting PNS involvement (13/19). Four of 19 patients with other ADDs fulfilled the seronegative NMOSD criteria. PLP1-IgG were also found in patients with MOGAD (11/42), more frequently with PNS involvement (p = 0.01), and in patients with MS (12/42), more frequently with atypical features (p < 0.001). PLP1-IgG-positive MOGAD had higher EDSS scores (p < 0.001) and PLP1-IgG-positive MS had higher severity scores (MSSS, p < 0.001) compared with those PLP1-IgG-negative. Overall, PLP1-IgG were found in 24.1% of patients with CNS+PNS-ADD, 21.2% with atypical MS, 8.3% with MOGAD, 12.0% with seronegative NMOSD, and 1.4% with typical MS. Their frequency within each diagnostic subgroup was consistent between the exploratory and validation cohorts. PLP1-IgG a) colocalized with their target on CBA-TBA, where their binding was abolished after immunoadsorption and fixation-induced conformational epitope alteration; b) mostly pertained to the IgG1/IgG3 subclass (68.3%) and were able to induce CDC; and c) coreacted with DM20 in all 12 patients with PNS involvement tested.

DISCUSSION

Conformational PLP1-IgG predominantly identify patients with non-MS ADDs. They should be tested mainly in those with CNS + PNS ADD, coherently with DM20-IgG coreactivity. PLP1-IgG could also be investigated as disease modifiers and prognostic markers in MS and MOGAD. Preliminary evidence supports their pathogenic potential.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Advances in Diagnosis and Management of Atypical Demyelinating Diseases

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