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Syc-Mazurek SB, Zhao-Fleming H, Guo Y, Tisavipat N, Chen JJ, Zekeridou A, Kournoutas I, Orme JJ, Block MS, Lucchinetti CF, Mustafa R, Flanagan EP. MOG Antibody-Associated Disease in the Setting of Metastatic Melanoma Complicated by Immune Checkpoint Inhibitor Use. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200249. [PMID: 38696737 PMCID: PMC11068306 DOI: 10.1212/nxi.0000000000200249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/13/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVES Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an autoimmune demyelinating disease rarely associated with malignancy. We report the clinical, MRI, immunopathology, and treatment response in a person with MOGAD and melanoma. METHODS This is a case report of a person with a multidisciplinary evaluation at a tertiary referral center. RESULTS A 52-year-old man presented with progressive encephalomyelitis that led to identification of metastatic melanoma. Investigations revealed positive MOG-IgG at high titers in serum (1:1,000; normal, <1:20) and CSF (1:4,096; normal, <1:2). MRI demonstrated multifocal T2 lesions with enhancement in the brain and spine. Brain biopsy showed demyelination and inflammation. MOG immunostaining was not present in the tumor tissue. He initially improved with methylprednisolone, plasmapheresis, prolonged oral steroid taper, and cancer-directed treatment with BRAF and MEK 1/2 inhibitors, but then developed bilateral optic neuritis. IV immunoglobulin (IVIG) was initiated. Five months later, he developed metastases and immune checkpoint inhibitor (ICI) treatment was started, which precipitated optic neuritis and myelitis despite IVIG and prednisone. Tocilizumab, an interleukin-6 receptor blocker, was started with excellent and sustained clinical and radiologic response. DISCUSSION This case revealed a presentation of MOGAD concurrent with melanoma without tumor MOG immunostaining. We highlight tocilizumab as a dual-purpose treatment of MOGAD and the neurologic immune-related adverse effect of ICI.
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Affiliation(s)
- Stephanie B Syc-Mazurek
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
| | - Hannah Zhao-Fleming
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
| | - Yong Guo
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
| | - Nanthaya Tisavipat
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
| | - John J Chen
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
| | - Anastasia Zekeridou
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
| | - Ioannis Kournoutas
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
| | - Jacob J Orme
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
| | - Matthew S Block
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
| | - Claudia F Lucchinetti
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
| | - Rafid Mustafa
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
| | - Eoin P Flanagan
- From the Departments of Neurology (S.B.S.-M., H.Z.-F., Y.G., N.T., J.J.C., A.Z., C.F.L., R.M., E.P.F.), Ophthalmology (J.J.C.), Internal Medicine (I.K.), and Oncology (J.J.O., M.S.B.), Mayo Clinic, Rochester, MN; and Neurology (C.F.L.), University of Texas at Austin
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Stefan KA, Ciotti JR. MOG Antibody Disease: Nuances in Presentation, Diagnosis, and Management. Curr Neurol Neurosci Rep 2024:10.1007/s11910-024-01344-z. [PMID: 38805147 DOI: 10.1007/s11910-024-01344-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE OF REVIEW Myelin oligodendrocyte glycoprotein antibody disease (MOGAD) is a distinct neuroinflammatory condition characterized by attacks of optic neuritis, transverse myelitis, and other demyelinating events. Though it can mimic multiple sclerosis and neuromyelitis optica spectrum disorder, distinct clinical and radiologic features which can discriminate these conditions are now recognized. This review highlights recent advances in our understanding of clinical manifestations, diagnosis, and treatment of MOGAD. RECENT FINDINGS Studies have identified subtleties of common clinical attacks and identified more rare phenotypes, including cerebral cortical encephalitis, which have broadened our understanding of the clinicoradiologic spectrum of MOGAD and culminated in the recent publication of proposed diagnostic criteria with a familiar construction to those diagnosing other neuroinflammatory conditions. These criteria, in combination with advances in antibody testing, should simultaneously lead to wider recognition and reduced incidence of misdiagnosis. In addition, recent observational studies have raised new questions about when to treat MOGAD chronically, and with which agent. MOGAD pathophysiology informs some of the relatively unique clinical and radiologic features which have come to define this condition, and similarly has implications for diagnosis and management. Further prospective studies and the first clinical trials of therapeutic options will answer several remaining questions about the peculiarities of this condition.
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Affiliation(s)
- Kelsey A Stefan
- Department of Neurology, University of South Florida, 13330 USF Laurel Drive, Tampa, FL, 33612, USA
| | - John R Ciotti
- Department of Neurology, University of South Florida, 13330 USF Laurel Drive, Tampa, FL, 33612, USA.
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Jean MJ, Samkoff L, Mohile N. Management of Paraneoplastic Syndromes in the Era of Immune Checkpoint Inhibitors. Curr Treat Options Oncol 2024; 25:42-65. [PMID: 38198120 DOI: 10.1007/s11864-023-01157-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 01/11/2024]
Abstract
OPINION STATEMENT Our understanding of paraneoplastic neurologic syndromes (PNS) has blossomed over the past few decades. Clinicians have access to more robust diagnostic criteria and have a heightened index of suspicion for these disorders. Nonetheless, treatment, which typically includes immunosuppression, and response to treatment, varies. Due to persistent difficulty in making a definitive diagnosis, we favor empiric treatment when a possible diagnosis of PNS is suspected, and other alternative causes have substantially been excluded (e.g., infections, toxic-metabolic derangements, metastasis, or leptomeningeal disease). Treatment of the underlying cancer, if identified, is the first therapeutic step and can prevent disease worsening and in rare cases, can reverse neurologic symptoms. In addition to anti-cancer treatment, first line immunotherapies, which include corticosteroids, intravenous immunoglobulins (IVIG), or plasma exchange (PLEX) are typically used. If partial or no benefit is seen, second line immunotherapeutic agents such as rituximab are considered. Additionally, the severity of the initial presentation and possible risk for relapse influences the use of the latter agents. Symptomatic management is also an important component in our practice and will depend on the syndrome being treated. One of the more novel entities we are facing currently is the management of immune checkpoint (ICI)-induced PNS. In those cases, current American Society of Clinical Oncology (ASCO) guidelines are followed.
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Affiliation(s)
- Maxime Junior Jean
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Lawrence Samkoff
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Nimish Mohile
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA.
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