Clinical Spectrum and Treatment of Neuromyelitis Optica Spectrum Disorders: Evolution and Current Status

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

OBJECTIVE

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

BACKGROUND

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

DESIGN/METHODS

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

RESULTS

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

CONCLUSION

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

Neuromyelitis optica spectrum disorder with acute brainstem manifestations as initial symptoms

Objective

To explore the clinical features and prognosis of patients with neuromyelitis optica spectrum disorder (NMOSD) initially presenting with acute brainstem symptoms.

Methods

The clinical data of NMOSD patients admitted to two medical centers were collected. The clinical characteristics, laboratory data, neuroimaging features and prognoses of patients with NMOSD with acute brainstem manifestations as initial symptoms (NMOSD-BSMIS) were analyzed. The clinical features and prognosis of patients with NMOSD-BSMIS and patients with NMOSD with other manifestations as initial symptoms (NMOSD-OMIS) were compared.

Results

Fifty-two patients (18.37 %, 52/283) initially presented with acute brainstem symptoms. Intractable nausea, vomiting or hiccups, diplopia, vertigo, headache, and facial hypoesthesia were the initial symptoms in most of the patients. The percentage of patients who were positive for serum aquaporin 4 (AQP4)-IgG antibodies was 81.63 % (40/49). MRI revealed that the lesions were usually located in the postrema, dorsal medulla oblongata, pons and other areas around the fourth ventricle. The early-stage misdiagnosis rate was 46.15 %. Compared with those in the non-misdiagnosed group, the age of onset of patients in the NMOSD-BSMIS group was older, and the proportion of patients admitted to the neurology department as the first department was lower in the misdiagnosed group. The annual relapse rate of patients who underwent NMOSD-BSMIS was significantly greater than that of patients who underwent NMOSD-OMIS (P < 0.01).

Conclusions

NMOSD patients can initially present with different brainstem symptoms. The early misdiagnosis rate of NMOSD-BSMIS is high. Moreover, if patients are older or initially admitted to nonneurological departments, they are more likely to be misdiagnosed. Moreover, the annual recurrence rate of NMOSD-BSMIS is greater in the early stage.

Case report: Overlap syndrome of neuromyelitis optica spectrum disorder with anti-Argonaute antibodies

Aquaporin-4 antibodies (AQP4-Abs) are a diagnostic marker for patients with a demyelinating disease called neuromyelitis optica spectrum disorder (NMOSD). Anti-Argonaute antibodies (AGO-Abs) present as potential biomarkers of the overlap syndrome between NMOSD and other autoimmune diseases. In this paper, we present the case of an adult woman with numbness, tingling, and burning sensations in her arms and subsequent bilateral internuclear ophthalmoplegia. Brain-cervical-thoracic magnetic resonance imaging (MRI) showed T2 hyperintensities in the dorsal brainstem and around the midbrain aqueduct and longitudinally transverse myelitis with homogeneous enhancement on gadolinium-enhanced MRI. The contemporaneous detection of AQP4- and AGO-Abs led to a definite diagnosis of overlap syndrome of NMOSD with AGO-Abs. The patient was treated with immunosuppressive agents, including corticosteroids and immunoglobulins, and achieved remission. This case highlights a novel phenotype of NMOSD with AGO-Abs overlap syndrome, which presents with relapsing brainstem syndrome and longitudinally extensive myelitis with acute severe neurological involvement. The promising prognosis of the disease could serve as a distinct clinical profile. Broad screening for antibodies against central nervous system autoimmune antigens is recommended in suspected patients with limited or atypical clinical manifestations.

The psychological burden of NMOSD - a mixed method study of patients and caregivers

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disorder of the central nervous system with common symptoms of rapid onset of eye pain, loss of vision, neck/back pain, paralysis, bowel and bladder dysfunction and heat sensitivity. The rare, unpredictable, and debilitating nature of NMOSD constitutes a unique psychological burden for patients and their caregivers, the specific nature and extent of which is not yet known. This mixed methods study, informed by both quantitative and qualitative data collected via self-report measures, focus groups, and in-depth interviews, aims to investigate and understand the psychological burden of patients with NMOSD and their caregiver/loved ones, so as to inform a specialized intervention. 31 adults living with NMOSD and 22 caregivers of people with NMOSD in the United States and Canada, recruited from NMOSD patient advocacy groups, social media groups, and through word of mouth from other participants, completed a battery of standardized self-report measures of anxiety, depression, trauma, cognitive fusion, valued living, and coping styles. Semi-structured focus group sessions were conducted via HIPAA-compliant Zoom with 31 patients, and separate focus groups were conducted with 22 caregivers. A subset of these samples, comprised of 16 patients and 11 caregivers, participated in individual semi-structured interviews, prioritizing inclusion of diverse perspectives. Descriptive statistics and bivariate correlations were run on quantitative self-report data using SPSS [Version 28.0.1]; data were stored in REDCap. Reflexive thematic analysis was employed regarding qualitative individual interview data. The majority of patients reported experiencing anxiety, depression, cognitive fusion, over-controlled coping, and lack of values-based living. Caregivers also reported heightened anxiety, cognitive fusion, and over-controlled coping, although they did not endorse clinically significant depression. Patient and caregiver degree of anxiety and of overcontrolled coping were both strongly positively correlated, likely affecting how both parties manage NMOSD-related stressors, both individually and as a dyad. Patients reported more anxiety, depression, psychological inflexibility, and lack of values-based living, compared with caregivers. Patient and caregiver narrative themes included mistrust of medical professionals, lack of support immediately following diagnosis, changes in relationships, deviation from values-based living, internalization of feelings, and avoidant coping strategies to manage the psychological burden of NMOSD. A novel mental health intervention targeting the specific psychological burden of life with NMOSD is proposed.

Inflammatory Demyelinating Diseases of the Central Nervous System

Over the past decades, a large number of immunomodulatory or immunosuppressive treatments have been approved to treat central nervous system (CNS) demyelinating disorders such as multiple sclerosis (MS). Owing to the heterogeneity of patients with CNS demyelinating diseases, there is no clinical treatment that can adequately control all disease subtypes. Although significant progress has been made for relapsing-remitting MS, effective management of the progressive phase of MS has not yet been achieved. This is at least in part caused by our incomplete understanding of the mechanisms driving disease progression, despite our increasing knowledge regarding the underlying cellular and molecular mechanisms. Here, we summarized our current knowledge regarding the mechanisms of CNS demyelinating disorders and their animal models to identify open questions and challenges for existing concepts. We also discussed potential strategies for the future design of immune therapies to treat CNS demyelinating disorders.

Early rituximab treatment reduces long-term disability in aquaporin-4 antibody-positive neuromyelitis optica spectrum

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.

Sociodemographic and Illness-Related Indicators to Predict the Status of Neuromyelitis Optica Spectrum Disorder (NMOSD) Five Years after Disease Onset

BACKGROUND

Neuromyelitis Optica Spectrum Disorder (NMOSD) is an autoimmune demyelinating disease of the central nervous system. Currently, no factors have been identified to predict the long-term course of NMOSD. To counter this, we analyzed data of 58 individuals with NMOSD at disease onset and about five years later.

METHODS

Medical records of 58 individuals with NMOSD (mean age: 31.13 years at disease onset; 86.2% female) were retrospectively analyzed. At baseline, a thorough medical and disease-related examination was performed; the same examination was repeated about five years later at follow-up, including treatment-related information. Mean outcome measure was the difference in EDSS (Expanded Disease Severity Scale) scores between baseline and follow-up.

RESULTS

Mean disease duration was 4.67 years. Based on the differences of the EDSS scores between baseline and follow-up, participants were categorized as improving (n = 39; 67.2%), unchanged (n = 13; 22.4%) and deteriorating (n = 6; 10.3%). Deteriorating was related to a higher progression index, and a higher number of attacks, while the annualized relapse rate reflecting the number of attacks per time lapse did not differ between the three groups. Improving was related to a higher intake of rituximab, and to a higher rate of seropositive cases. Unchanged was related to a lower rate of seropositive cases. Factors such as age, gender, somatic and psychiatric comorbidities, symptoms at disease onset, relapse rates, number and location of cervical plaques, or brain plaques and thoracolumbar plaques at baseline did not differ between those improving, deteriorating or remaining unchanged.

CONCLUSIONS

Among a smaller sample of individuals with NMOSD followed-up about five years later, individuals deteriorating over time reported a higher progression index, while the annualized relapse rate was unrelated to the progress of disease. Overall, it appears that the course of NMOSD over a time lapse of about five years after disease onset is highly individualized. Accordingly, treatment regimen demands a highly individually tailored approach.

Psychiatric symptoms as initial manifestation in neuromyelitis optica spectrum disorder without cortical lesions: A report of two cases

Diagnosing neuromyelitis optica spectrum disorder (NMOSD) remains a challenge, especially in patients with atypical presentations. Here, we describe two NMOSD patients who initially presented psychiatric symptoms without cortical lesions. This report expands our understanding of the possible presentations of NMOSD. Knowledge of rare initial symptoms may allow timely diagnosis and early therapeutic intervention, preventing more severe attacks affecting the spinal cord or eyes.

Superficial Macula Capillary Complexity Changes Are Associated With Disability in Neuromyelitis Optica Spectrum Disorders

Purpose: We examined the macular microvascular changes of the macula in neuromyelitis optica spectrum disorder (NMOSD) patients and its association with their disability and other clinical variables.

Methods: Thirty-four NMOSD (13 patients without optic neuritis, NMOSD-NON, and 21 patients with a history of optic neuritis, NMOSD-ON) and 44 healthy controls (HCs) were included in the study. Optical coherence tomographic angiography (OCTA) was used to image the superficial (SCP), deep (DCP), and whole capillary plexus (WCP) in a 2.5-mm-diameter concentric circle [excluding the foveal avascular zone (FAZ)]. An algorithm (D_box) was used to quantify the complexity of the three capillary layers by fractal analysis. We also evaluated the expanded disability scale status (EDSS).

Results: D_box values were significantly reduced in SCP (p < 0.001), DCP (p < 0.001), and WCP (p = 0.003) of NMOSD when compared with HCs. D_box values were significantly reduced in NMOSD eyes with optic neuritis when compared with healthy controls (p < 0.001) and eyes without optic neuritis (p = 0.004) in the SCP. In the DCP, eyes with optic neuritis showed significantly reduced D_box values when compared with eyes without optic neuritis (p = 0.016) and healthy controls (p < 0.001); eyes without optic neuritis showed significantly reduced D_box values (p = 0.007) in the DCP when compared with healthy controls. A significant negative correlation (Rho = −0.475, p = 0.005) was shown between the superficial macula D_box values and the EDSS in NMOSD patients. Additionally, a negative correlation (Rho = −0.715, p = 0.006) was seen in the superficial D_box values in [e]eyes without optic neuritis and EDSS.

Conclusions: Macular microvascular damage in the superficial plexus is associated with disability in NMOSD. Macular microvascular alterations arise independently of the occurrence of ON in NMOSD.

Pain in NMOSD and MOGAD: A Systematic Literature Review of Pathophysiology, Symptoms, and Current Treatment Strategies

Neuromyelitis optica spectrum disorders (NMOSDs) and myelin oligodendrocyte glycoprotein-antibody-associated disease (MOGAD) are autoimmune inflammatory disorders of the central nervous system (CNS). Pain is highly prevalent and debilitating in NMOSD and MOGAD with a severe impact on quality of life, and there is a critical need for further studies to successfully treat and manage pain in these rare disorders. In NMOSD, pain has a prevalence of over 80%, and pain syndromes include neuropathic, nociceptive, and mixed pain, which can emerge in acute relapse or become chronic during the disease course. The impact of pain in MOGAD has only recently received increased attention, with an estimated prevalence of over 70%. These patients typically experience not only severe headache, retrobulbar pain, and/or pain on eye movement in optic neuritis but also neuropathic and nociceptive pain. Given the high relevance of pain in MOGAD and NMOSD, this article provides a systematic review of the current literature pertaining to pain in both disorders, focusing on the etiology of their respective pain syndromes and their pathophysiological background. Acknowledging the challenge and complexity of diagnosing pain, we also provide a mechanism-based classification of NMOSD- and MOGAD-related pain syndromes and summarize current treatment strategies.

Simultaneous bilateral optic neuritis in China: clinical, serological and prognostic characteristics

PURPOSE

To analyse the clinical characteristics of simultaneous bilateral ON patients in China.

METHODS

This retrospective study was done on 51 primary bilateral ON patients between April 2008 and July 2016 at the Chinese People's Liberation Army General Hospital. Fifty eight primary unilateral ON patients formed the control group. Demographic data, clinical course, serum autoantibody status, connective tissue disorders, magnetic resonance imaging and visual functions were compared.

RESULTS

The mean age at disease onset in the bilateral group was younger than that of the unilateral group (p = 0.001). Cerebrospinal fluid (CSF) total cell count and CSF total protein were significantly higher in the bilateral group (p = 0.001, p = 0.025). Aquaporin-4 (AQP4) antibodies were detected in 39% and 21% of the bilateral and unilateral patients, respectively (p = 0.03). Twenty two percent of the bilateral patients fulfilled the diagnosis of neuromyelitis optica (NMO); 7% in the unilateral group did so (p = 0.03). Serum autoantibodies (ANA, SSA, SSB, etc.) were found in 49% of the bilateral patients and 29% of the unilateral patients (p = 0.035). After treatment, the bilateral patients were significantly more prone to severe visual disability eventually than their unilateral counterparts (p = 0.002). Patients with MOG-IgG (myelin oligodendrocyte glycoprotein-IgG) represented 26% of the patients negative for AQP4-IgG. Myelin oligodendrocyte glycoprotein-IgG (MOG-IgG) sero-positive patients were more likely to recover than the other patients (p < 0.001).

CONCLUSION

Simultaneous bilateral ON is a severe disorder closely related to serum AQP4-IgG and MOG-IgG, which are more likely to involve younger people and incur severe visual disability eventually. Myelin oligodendrocyte glycoprotein-IgG (MOG-IgG) sero-positive patients have higher risk of ON relapses and better visual prognosis.

Role of Glutamatergic Excitotoxicity in Neuromyelitis Optica Spectrum Disorders

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disorder mediated by immune-humoral responses directed against central nervous system (CNS) antigens. Most patients are positive for specific immunoglobulin G (IgG) auto-antibodies for aquaporin-4 (AQP4), a water channel present in astrocytes. Antigen-antibody binding promotes complement system cascade activation, immune system cell infiltration, IgG deposition, loss of AQP4 and excitatory amino acid transporter 2 (EAAT2) expression on the astrocytic plasma membrane, triggering necrotic destruction of spinal cord tissue and optic nerves. Astrocytes are very important cells in the CNS and, in addition to supporting other nerve cells, they also regulate cerebral homeostasis and control glutamatergic synapses by modulating neurotransmission in the cleft through the high-affinity glutamate transporters present in their cell membrane. Specific IgG binding to AQP4 in astrocytes blocks protein functions and reduces EAAT2 activity. Once compromised, EAAT2 cannot take up free glutamate from the extracellular space, triggering excitotoxicity in the cells, which is characterized by overactivation of glutamate receptors in postsynaptic neurons. Therefore, the longitudinally extensive myelitis and optic neuritis lesions observed in patients with NMOSD may be the result of primary astrocytic damage triggered by IgG binding to AQP4, which can activate the immune-system cascade and, in addition, downregulate EAAT2. All these processes may explain the destructive lesions in NMOSD secondary to neuroinflammation and glutamatergic excitotoxicity. New or repurposed existing drugs capable of controlling glutamatergic excitotoxicity may provide new therapeutic options to reduce tissue damage and permanent disability after NMOSD attacks.

Expression of OX40 Gene and its Serum Levels in Neuromyelitis Optica Patients

Neuromyelitis optica (NMO), also known as Devic's disease, is an autoimmune disorder of the central nervous system (CNS) in which immune system cells and antibodies primarily attack the optic nerves and the spinal cord. OX40 (CD134) is a tumor necrosis factor (TNF)-receptor family member expressed primarily on activated CD4+ and CD8+ T-cells. In an autoimmune disease, OX40 is typically up-regulated at sites of inflammation, and increases in the number of peripheral CD4+ T-cells expressing OX40. OX40 and its ligand OX40L are key TNF members that augment T-cell expansion, cytokine production, and promote T-cell survival. The aim of this study was to evaluate and compare of OX40 gene expression and its serum levels in patients with NMO and healthy controls. Twenty sex-/age-matched healthy controls (HC) (median age = 32 years, 15 females/5 males) were engaged for the present study. Expression of OX40 at the transcript level and serum protein levels were measured by quantitative real-time polymerase chain reaction (qRT-PCR) and enzyme-linked immunosorbent assays, respectively. The results indicated OX40 expression in patients was significantly lower than in healthy controls (p = 0.001). However, the serum level of OX40 was not significantly different between groups (p = 0.37). In addition, the results indicated that CD134 expression was not age-related (p = 0.041). Overall, this study suggests to us that OX40 levels are not a suitable marker for diagnosis or treatment of NMO.

Contiguous and symmetrical disease expansion and massive necrosis of the cerebral white matter in a patient with neuromyelitis optica

The present report discusses the case of a woman with neuromyelitis optica (NMO) who exhibited bilateral optic neuritis, longitudinally extensive myelitis, serum anti-aquaporin-4 antibodies, and a unique pattern of white matter involvement. The disease duration was 26 years, and the patient died at the age of 65 years. Sequential magnetic resonance images obtained during the last 6 years of life revealed leukoencephalopathy-like lesions extending symmetrically and contiguously from the periventricular regions, which had begun to transform into multiple cavities with semi-annular partitions. This unique pattern of white matter abnormalities should thus be considered among those associated with NMO.

Comprehensive analysis of patients with neuromyelitis optica spectrum disorder (NMOSD) combined with chronic hepatitis B (CHB) infection and seropositive for anti-aquaporin-4 antibody

Previous research indicated the association between hepatitis B virus (HBV) infection/vaccination and the onset of demyelinating diseases. However, most of these studies were single case reports, and comprehensive data are still scarce. Here we present a comprehensive analysis of 10 patients with neuromyelitis optica spectrum disorder (NMOSD) combined with chronic hepatitis B (CHB) infection and seropositive for anti-aquaporin-4 antibody (AQP4-Ab). Demographic, clinical, laboratory, neuroimaging, outcome, and follow-up data of the 10 patients were retrospectively analyzed. The median age at the onset of NMOSD was 35 years (range 25-43). Nine patients were female (90%). All patients were positive for HBsAg and had been diagnosed with CHB earlier than with NMOSD. One patient had an autoimmune disease. All patients had normal thyroid function. Paresthesia and visual impairment were the most common clinical symptoms. The cerebrospinal fluid (CSF) parameters (protein and glucose) were normal in 10 cases, whereas slightly higher CSF white blood cell count was detected in 3 patients. The brain and spinal cord magnetic resonance imaging findings were abnormal in 8 patients. All patients were treated with hormone and immunosuppressive therapy, and anti-HBV agents. Patients with detectable serum HBV DNA were more prone to liver damage after receiving high doses of corticosteroids. In 8 patients, the symptoms improved before they were discharged. Two patients with optic neuritis (ON) maintained the symptoms. A month later, 1/8 patient had recurrence of symptoms, and one ON patient progressed to NMO. Overall, the characteristics of NMOSD patients with CHB and seropositive for AQP4-Ab are usually nonspecific. Abnormal liver function test results in NMOSD patients should be a warning of possible CHB infection, and the treatment should be modified accordingly.

Diagnosis and management of neuromyelitis optica spectrum disorders - An update

Neuromyelitis optica (NMO) and Neuromyelitis optica spectrum disorders (NMOSD) are a group of autoimmune conditions characterized by inflammatory involvement of the optic nerve, spinal cord and central nervous system. Novel evidence showed a key role of autoantibodies against aquaporin-4 immunoglobulin G (AQP4 IgG) in the pathogenesis of NMOSD and, recently, new classification and diagnostic criteria have been adopted to facilitate an earlier identification and improve the management of these conditions. Diagnosis of NMOSD is currently based on clinical, neuroimaging and laboratory features. Standard treatment is based on the use of steroids and immunosuppressive drugs and aims to control the severity of acute attacks and to prevent relapses of the disease. This review gives an update of latest knowledge of NMOSD and NMO, emphasizing the novel diagnostic criteria and both current and future therapeutic approaches.

Prevalence of neuromyelitis optica spectrum disorder in the multi-ethnic Penang Island, Malaysia, and a review of worldwide prevalence

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) occurs worldwide in all ethnicities. Recently, population-based studies have shown that NMOSD is more common among non-White populations. There is scarce data about NMOSD prevalence in South East Asian populations.

METHODS

(1) A population-based study was undertaken to estimate NMOSD prevalence in the multi-ethnic Penang Island, Malaysia, comprising Chinese, Malays, and Indians. Medical records of NMOSD patients followed up at the Penang General Hospital (the neurology referral centre in Penang Island) were reviewed. The 2015 diagnostic criteria of the International Panel for NMO Diagnosis were used for case ascertainment. (2) A review of population-based prevalence studies of NMOSD worldwide was carried out. PubMed and conference proceedings were searched for such studies.

RESULTS

Of the 28 NMOSD patients, 14 were residents of Penang Island on prevalence day [13 (93%) Chinese and one (7%) Malay]. All 14 patients were females and aquaporin 4 seropositive. The prevalence of NMOSD in Penang Island was 1.99/100,000 population; according to ethnicities, the prevalence in Chinese was significantly higher than in Malays (3.31/100,000 vs 0.43/100,000, respectively, p = 0.0195).

CONCLUSION

Based on our and other population-based studies, among Asians, East Asian origin populations (Chinese and Japanese) appear to have higher NMOSD prevalence than other Asian ethnic groups. Worldwide, Blacks seem to have the highest NMOSD prevalence. More studies in different geographical regions and ethnic groups will be useful to further inform about potential factors in NMOSD pathogenesis.

Frequency of autoimmune disorders and autoantibodies in patients with neuromyelitis optica

OBJECTIVE

The aim of this study was to report the frequency of autoimmune disorders and autoantibodies in 22 patients with neuromyelitis optica (NMO), as well as whether the seropositivity for autoantibodies differs between anti-aquaporin 4 (AQP4) positive and AQP4 negative NMO patients.

METHODS

Demographic, medical records, and a profile of autoantibodies were evaluated in 22 NMO patients, including AQP4, anti-thyroid-stimulating hormone receptor, antinuclear antibodies (ANA), anti-thyroperoxidase (anti-TPO), anti-thyroglobulin (anti-Tg), anti-double-stranded DNA, anti-neutrophil cytoplasmic, anti-cyclic citrullinate peptide, rheumatoid factor, anti-SSA/Ro, anti-SSB/La, anti-Smith antibodies (anti-Sm), anti-ribonucleoprotein, anti-nucleosome, and anti-Scl70. Thyroid-stimulating hormone and free thyroxin were measured.

RESULTS

The frequency of women was higher than men (95.5% vs. 4.5%) and 68.2% were Afro-Brazilians. Six (27.3%) patients presented other autoimmune disorders, such as Hashimoto thyroiditis (n=2), Graves' disease (n=1), juvenile idiopathic arthritis (n=1), systemic lupus erythematosus and systemic sclerosis (n=1), and Raynaud's phenomenon (n=1). The most frequent autoantibodies were anti-AQP4 (54.5%), anti-nucleosome (31.8%), ANA (27.3%), anti-TPO (22.7%), and anti-Tg (22.7%). Difference was not observed in the frequency of autoimmune disorders when the patients were compared according to their anti-AQP4 status.

CONCLUSION

The results of the present study underscored that the NMO patients present high frequency of autoantibodies against cellular antigens and the presence of autoimmune disorders. Further studies with large number of NMO patients may contribute to advances in the understanding of NMO disease mechanisms.

Plasma complement biomarkers distinguish multiple sclerosis and neuromyelitis optica spectrum disorder

Background:

Multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) are autoimmune inflammatory demyelinating diseases of the central nervous system. Although distinguished by clinicoradiological and demographic features, early manifestations can be similar complicating management. Antibodies against aquaporin-4 support the diagnosis of NMOSD but are negative in some patients. Therefore, there is unmet need for biomarkers that enable early diagnosis and disease-specific intervention.

Objective:

We investigated whether plasma complement proteins are altered in MS and NMOSD and provide biomarkers that distinguish these diseases.

Methods:

Plasma from 54 NMOSD, 40 MS and 69 control donors was tested in multiplex assays measuring complement activation products and proteins. Using logistic regression, we tested whether combinations of complement analytes distinguished NMOSD from controls and MS.

Results:

All activation products were elevated in NMOSD compared to either control or MS. Four complement proteins (C1inh, C1s, C5 and FH) were higher in NMOSD compared to MS or controls. A model comprising C1inh and terminal complement complex (TCC) distinguished NMOSD from MS (area under the curve (AUC): 0.98), while C1inh and C5 distinguished NMOSD from controls (AUC: 0.94).

Conclusion:

NMOSD is distinguished from MS by plasma complement biomarkers. Selected complement analytes enable differential diagnosis. Findings support trials of anti-complement therapies in NMOSD.

Imaging of Optic Neuropathy and Chiasmal Syndromes

Optic neuropathy involves loss of visual acuity, color vision, and visual field defect with a swollen, pale, anomalous, or normal optic disc seen on fundoscopy. Chiasmal disorders classically present with gradual onset of vision loss, bitemporal hemianopsia, and occasionally, endocrinopathy if the pituitary gland and/or hypothalamus are the causes or are involved. Advance in neuroimaging, especially magnetic resonance (MR) imaging, can reveal pathologic conditions previously detected only clinically. Some entities have imaging characteristics, leading to appropriate treatment without requiring tissue biopsies. Imaging also provides disease surveillance and posttreatment assessment, with computed tomography and MR imaging being complementary to each other.

Acute disseminated encephalomyelitis: current knowledge and open questions

Acute disseminated encephalomyelitis (ADEM) is usually an acute, multi-focal, and monophasic immune-mediated disease of the central nervous system. The disorder is mainly a condition of the pediatric age group, but neurologists are also involved in the management of adult patients. The lack of defined diagnostic criteria for ADEM underlies the limited understanding of its epidemiology, etiology, pathogenesis, course, prognosis, therapy, as well as the association with, and distinction from, multiple sclerosis. The present review summarizes current knowledge and outlines unanswered questions the answers to which should be eventually provided through a synergistic combination of clinical and basic research.

Epidemiological, clinical, and immunological characteristics of neuromyelitis optica: A review

The aim of this study was to review the epidemiological and clinical characteristics of neuromyelitis optica (NMO) and the immunopathological mechanisms involved in the neuronal damage. NMO is an inflammatory demyelinating autoimmune disease of the central nervous system that most commonly affects the optic nerves and spinal cord. NMO is thought to be more prevalent among non-Caucasians and where multiple sclerosis (MS) prevalence is low. NMO follows a relapsing course in more than 80-90% of cases, which is more commonly in women. It is a complex disease with an interaction between host genetic and environmental factors and the main immunological feature is the presence of anti-aquaporin 4 (AQP4) antibodies in a subset of patients. NMO is frequently associated with multiple other autoantibodies and there is a strong association between NMO with other systemic autoimmune diseases. AQP4-IgG can cause antibody-dependent cellular cytotoxicity (ADCC) when effector cells are present and complement-dependent cytotoxicity (CDC) when complement is present. Acute therapies, including corticosteroids and plasma exchange, are designed to minimize injury and accelerate recovery. Several aspects of NMO pathogenesis remain unclear. More advances in the understanding of NMO disease mechanisms are needed in order to identify more specific biomarkers to NMO diagnosis.