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Nasr Z, Virupakshaiah A, Schoeps VA, Cherbuin N, Casper TC, Waltz M, Hart J, Rodriguez M, Gorman MP, Benson LA, Chitnis T, Rensel M, Abrams A, Krupp L, Waldman AT, Lotze T, Aaen GS, Mar S, Schreiner T, Wheeler Y, Rose J, Shukla NM, Barcellos LF, Lucas R, Waubant E. Gene-environment interactions and risk of pediatric-onset multiple sclerosis associated with time spent outdoors. Mult Scler Relat Disord 2024; 82:105351. [PMID: 38141560 DOI: 10.1016/j.msard.2023.105351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/12/2023] [Accepted: 12/03/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Our previous study identified a significant association between lower time spent outdoors, as a proxy of sun exposure, and a higher risk of pediatric-onset multiple sclerosis (POMS). UV radiation modulates the expression of several genes, but it is unknown whether these genes modify the effect of sun exposure on POMS risk. METHODS In an age- and sex-matched case-control study, we evaluated the additive and multiplicative interactions between time spent outdoors and genetic non-HLA risk variants for developing POMS within the metabolic pathways of UV radiation, including CD28(rs6435203), CD86(rs9282641), and NFkB1(rs7665090) and the top two HLA risk factors (presence of DRB1×15 and absence of A*02). RESULTS In an adjusted model (332 POMS cases, 534 healthy controls), greater time compared to <30 min/day spent outdoors during the prior summer and higher UV radiation dose were associated with decreased odds of POMS (OR 0.66, 95% CI 0.56-0.78, p < 0.001; OR 0.78, 95 % CI 0.62-0.98, p = 0.04, respectively). No significant additive or multiplicative interactions were found between risk factors. CONCLUSIONS The exploration of gene-environment interactions in the risk of developing MS can unravel the underlying mechanisms involved. Although we do not have evidence that our candidate genes contribute to interactions, other genes may.
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Affiliation(s)
- Zahra Nasr
- UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA.
| | - Akash Virupakshaiah
- UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Vinicius Andreoli Schoeps
- UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Nicolas Cherbuin
- Centre for Research on Ageing, Health and Wellbeing, Australian National University, Canberra, Australia
| | - T Charles Casper
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael Waltz
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Janace Hart
- UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | | | - Mark P Gorman
- Boston Childrens Hospital, Boston, Massachusetts, USA
| | | | - Tanuja Chitnis
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Lauren Krupp
- New York University Medical Center, New York City, New York, USA
| | - Amy T Waldman
- Division of Child Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tim Lotze
- Texas Children's Hospital, Houston, Texas, USA
| | - Gregory S Aaen
- Loma Linda University Children's Hospital, Loma Linda, California, USA
| | - Soe Mar
- Washington University in St. Louis, St Louis, Missouri, USA
| | - Teri Schreiner
- Childrens Hospital Colorado/University of Colorado, Aurora, Colorado, USA
| | | | - John Rose
- George E. Wahlen Department of Veterans Affairs Medical Center, University of Utah, Salt Lake City, UT, USA
| | - Nikita Melani Shukla
- Baylor College of Medicine/Texas Children's Hospital, Neurology and Developmental Neuroscience, Houston, Texas, USA
| | - Lisa F Barcellos
- Genetic Epidemiology and Genomics Laboratory, Divisions of Epidemiology and Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Robyn Lucas
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia
| | - Emmanuelle Waubant
- UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
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Schoeps VA, Zhou X, Horton MK, Zhu F, McCauley KE, Nasr Z, Virupakshaiah A, Gorman MP, Benson LA, Weinstock‐Guttman B, Waldman A, Banwell BL, Bar‐Or A, Marrie RA, van Domselaar G, O'Mahony J, Mirza AI, Bernstein CN, Yeh EA, Casper TC, Lynch SV, Tremlett H, Baranzini S, Waubant E. Short-chain fatty acid producers in the gut are associated with pediatric multiple sclerosis onset. Ann Clin Transl Neurol 2024; 11:169-184. [PMID: 37955284 PMCID: PMC10791026 DOI: 10.1002/acn3.51944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/23/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE The relationship between multiple sclerosis and the gut microbiome has been supported by animal models in which commensal microbes are required for the development of experimental autoimmune encephalomyelitis. However, observational study findings in humans have only occasionally converged when comparing multiple sclerosis cases and controls which may in part reflect confounding by comorbidities and disease duration. The study of microbiome in pediatric-onset multiple sclerosis offers unique opportunities as it is closer to biological disease onset and minimizes confounding by comorbidities and environmental exposures. METHODS A multicenter case-control study in which 35 pediatric-onset multiple sclerosis cases were 1:1 matched to healthy controls on age, sex, self-reported race, ethnicity, and recruiting site. Linear mixed effects models, weighted correlation network analyses, and PICRUSt2 were used to identify microbial co-occurrence networks and for predicting functional abundances based on marker gene sequences. RESULTS Two microbial co-occurrence networks (one reaching significance after adjustment for multiple comparisons; q < 0.2) were identified, suggesting interdependent bacterial taxa that exhibited association with disease status. Both networks indicated a potentially protective effect of higher relative abundance of bacteria observed in these clusters. Functional predictions from the significant network suggested a contribution of short-chain fatty acid producers through anaerobic fermentation pathways in healthy controls. Consistent family-level findings from an independent Canadian-US study (19 case/control pairs) included Ruminococaccaeae and Lachnospiraceae (p < 0.05). Macronutrient intake was not significantly different between cases and controls, minimizing the potential for dietary confounding. INTERPRETATION Our results suggest that short-chain fatty acid producers may be important contributors to multiple sclerosis onset.
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Affiliation(s)
- Vinicius A. Schoeps
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Xiaoyuan Zhou
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Mary K. Horton
- Division of EpidemiologyUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Feng Zhu
- Division of NeurologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Kathryn E. McCauley
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Zahra Nasr
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Akash Virupakshaiah
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Mark P. Gorman
- Department of NeurologyBoston Children's HospitalBostonMassachusettsUSA
| | - Leslie A. Benson
- Department of NeurologyBoston Children's HospitalBostonMassachusettsUSA
| | | | - Amy Waldman
- Department of NeurologyChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Brenda L. Banwell
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Amit Bar‐Or
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ruth Ann Marrie
- Department of Internal MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - Gary van Domselaar
- Department of Internal MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - Julia O'Mahony
- Department of Internal MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - Ali I. Mirza
- Division of NeurologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | | | - E. Ann Yeh
- The Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | | | - Susan V. Lynch
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Helen Tremlett
- Division of NeurologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Sergio Baranzini
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Emmanuelle Waubant
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
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Wilson E, Howard D, Daniel D, Taylor L, Gorman MP, Benson LA. Disease modifying treatment for pediatric onset multiple sclerosis: Ethical considerations and strategies to navigate parental refusal. Mult Scler Relat Disord 2023; 79:104970. [PMID: 37690437 DOI: 10.1016/j.msard.2023.104970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Elizabeth Wilson
- Boston Children's Hospital, Department of Neurology 300 Longwood Avenue, Boston, MA 02115, United States; Massachusetts General Brigham Hospital, Department of Neurology 55 Fruit Street, Boston, MA 02114, United States.
| | - Danielle Howard
- Massachusetts General Brigham Hospital, Department of Neurology 55 Fruit Street, Boston, MA 02114, United States
| | - Dennis Daniel
- Boston Children's Hospital, Critical care medicine 300 Longwood Avenue, Boston, MA 02115, United States
| | - Lisa Taylor
- Boston Children's Hospital, Office of Ethics 300 Longwood Avenue, Boston, MA 02115, United States
| | - Mark P Gorman
- Boston Children's Hospital, Department of Neurology 300 Longwood Avenue, Boston, MA 02115, United States
| | - Leslie A Benson
- Boston Children's Hospital, Department of Neurology 300 Longwood Avenue, Boston, MA 02115, United States
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Khaytin I, Victor AK, Barclay SF, Benson LA, Slattery SM, Rand CM, Kurek KC, Weese-Mayer DE. Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD): a collaborative review of the current understanding. Clin Auton Res 2023; 33:251-268. [PMID: 37162653 DOI: 10.1007/s10286-023-00936-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/01/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE To provide an overview of the discovery, presentation, and management of Rapid-onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation (ROHHAD). To discuss a search for causative etiology spanning multiple disciplines and continents. METHODS The literature (1965-2022) on the diagnosis, management, pathophysiology, and potential etiology of ROHHAD was methodically reviewed. The experience of several academic centers with expertise in ROHHAD is presented, along with a detailed discussion of scientific discovery in the search for a cause. RESULTS ROHHAD is an ultra-rare syndrome with fewer than 200 known cases. Although variations occur, the acronym ROHHAD is intended to alert physicians to the usual sequence or unfolding of the phenotypic presentation, including the full phenotype. Nearly 60 years after its first description, more is known about the pathophysiology of ROHHAD, but the etiology remains enigmatic. The search for a genetic mutation common to patients with ROHHAD has not, to date, demonstrated a disease-defining gene. Similarly, a search for the autoimmune basis of ROHHAD has not resulted in a definitive answer. This review summarizes current knowledge and potential future directions. CONCLUSION ROHHAD is a poorly understood, complex, and potentially devastating disorder. The search for its cause intertwines with the search for causes of obesity and autonomic dysregulation. The care for the patient with ROHHAD necessitates collaborative international efforts to advance our knowledge and, thereby, treatment, to decrease the disease burden and eventually to stop, and/or reverse the unfolding of the phenotype.
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Affiliation(s)
- Ilya Khaytin
- Center for Autonomic Medicine in Pediatrics (CAMP), Division of Autonomic Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Stanley Manne Children's Research Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - A Kaitlyn Victor
- College of Graduate Health Sciences, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sarah F Barclay
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Susan M Slattery
- Center for Autonomic Medicine in Pediatrics (CAMP), Division of Autonomic Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Stanley Manne Children's Research Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Casey M Rand
- Center for Autonomic Medicine in Pediatrics (CAMP), Division of Autonomic Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Stanley Manne Children's Research Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kyle C Kurek
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Debra E Weese-Mayer
- Center for Autonomic Medicine in Pediatrics (CAMP), Division of Autonomic Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Stanley Manne Children's Research Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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5
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Hayes LH, Hopkins SE, Liu S, Pardo CA, Garcia-Dominguez MA, Oleszek J, Yea C, Ciftci-Kavaklioglu B, Yeh EA, Dean J, Sadowsky CL, Desai J, Wiegand S, Farias-Moeller R, Nash K, Thakur KT, Vargas WS, Hong-Routson SJ, Yeshokumar A, Zhou MS, Makhani N, Wilson-Murphy M, Bove R, Zhang B, Benson LA. Challenges in the Clinical Recognition of Acute Flaccid Myelitis and its Implications. J Pediatr 2023; 253:55-62.e4. [PMID: 36115622 DOI: 10.1016/j.jpeds.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To explore the challenges in diagnosing acute flaccid myelitis (AFM) and evaluate clinical features and treatment paradigms associated with under recognition. STUDY DESIGN This was a retrospective multicenter study of pediatric patients (≤18 years) who were diagnosed with AFM from 2014 to 2018 using the Centers for Disease Control and Prevention's case definition. RESULTS In 72% of the cases (126 of 175), AFM was not considered in the initial differential diagnosis (n = 108; 61.7%) and/or the patient was not referred for acute care (n = 90; 51.4%) at the initial clinical encounter, and this did not improve over time. Although many features of the presentation were similar in those initially diagnosed with AFM and those who were not; preceding illness, constipation, and reflexes differed significantly between the 2 groups. Patients with a non-AFM initial diagnosis more often required ventilatory support (26.2% vs 12.2%; OR, 0.4; 95% CI, 0.2-1.0; P = .05). These patients received immunomodulatory treatment later (3 days vs 2 days after neurologic symptom onset; 95% CI, -2 to 0; P = .05), particularly intravenous immunoglobulin (5 days vs 2 days; 95% CI, -4 to -2; P < .001). CONCLUSIONS Delayed recognition of AFM is concerning because of the risk for respiratory decompensation and need for intensive care monitoring. A non-AFM initial diagnosis was associated with delayed treatment that could have a clinical impact, particularly as new treatment options emerge.
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Affiliation(s)
- Leslie H Hayes
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Sarah E Hopkins
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, MA
| | - Shanshan Liu
- Department of Neurology and Institutional Centers for Clinical and Translational Research Biostatistics and Research Design Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MA
| | | | - Joyce Oleszek
- Department of Physical Medicine & Rehabilitation, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Carmen Yea
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - E Ann Yeh
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Janet Dean
- Department of Physical Medicine and Rehabilitation, International Center for Spinal Cord Injury, Johns Hopkins School of Medicine, Kennedy Krieger Institute, Baltimore, MD
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, International Center for Spinal Cord Injury, Johns Hopkins School of Medicine, Kennedy Krieger Institute, Baltimore, MD
| | - Jay Desai
- Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sarah Wiegand
- Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Raquel Farias-Moeller
- Division of Child Neurology, Department of Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Kendall Nash
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA
| | - Kiran T Thakur
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY
| | - Wendy S Vargas
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY
| | - Sue J Hong-Routson
- Division of Critical Care, Departments of Pediatrics & Neurology, Lurie Children's Hospital of Chicago, Chicago, IL
| | - Anusha Yeshokumar
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Melissa S Zhou
- Department of Pediatrics, Yale School of Medicine, New Haven, CT; Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Naila Makhani
- Department of Pediatrics, Yale School of Medicine, New Haven, CT; Department of Neurology, Yale School of Medicine, New Haven, CT
| | | | - Riley Bove
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA
| | - Bo Zhang
- Department of Neurology and Institutional Centers for Clinical and Translational Research Biostatistics and Research Design Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Boston, MA.
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Machado-Rivas F, Jaimes C, Scherrer B, Benson LA, Gorman MP, Warfield SK, Afacan O. Evaluation of white matter microstructure in pediatric onset multiple sclerosis with diffusion compartment imaging. J Neuroimaging 2022; 32:1098-1108. [PMID: 36036739 DOI: 10.1111/jon.13038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/20/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Pediatric-onset multiple sclerosis (POMS) shows earlier axonal involvement and greater axonal loss than in adults. We aim to characterize the white matter (WM) microstructural changes in POMS using a diffusion compartment imaging (DCI) model and compare it to standard diffusion tensor imaging (DTI). METHODS Eleven patients (2 males, mean age 18.8 ± 3.9 years) with a diagnosis of relapsing and remitting POMS (mean age at disease onset 13.8 ± 2.9 years, mean duration 5.1 ± 1.9 years) and healthy controls (8 males, mean age 26.4 ± 6.5 years) were recruited and imaged at 3 T. A 90-gradient set Cube and Sphere acquisition and a novel DCI model known as DIstribution of Anisotropic MicrOstructural eNvironments with Diffusion-weighted imaging (DIAMOND) were used to calculate a single anisotropic compartment, an isotropic compartment, and a free diffusion compartment. Lesions and contralateral normal-appearing white matter (NAWM) in patients and whole brain WM for controls were labeled. RESULTS Eleven patients and 11 controls were recruited. When comparing lesions and contralateral NAWM in patients using DCI, compartmental axial diffusivity, radial diffusivity (cRD), and mean diffusivity (cMD) were higher in lesions. Conversely, compartmental fractional anisotropy (cFA) and heterogeneity index were lower in lesions. An analysis of DTI equivalents showed the same trends. In whole-brain NAWM of patients compared to controls, cRD and cMD were higher and cFA was lower in patients. CONCLUSION Lesions in POMS can be accurately characterized by a DCI model. Incipient changes in NAWM seen in DCI may not be readily observable by DTI.
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Affiliation(s)
- Fedel Machado-Rivas
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Camilo Jaimes
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benoit Scherrer
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Simon K Warfield
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Onur Afacan
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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7
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Mandel‐Brehm C, Benson LA, Tran B, Kung AF, Mann SA, Vazquez SE, Retallack H, Sample HA, Zorn KC, Khan LM, Kerr LM, McAlpine PL, Zhang L, McCarthy F, Elias JE, Katwa U, Astley CM, Tomko S, Dalmau J, Seeley WW, Pleasure SJ, Wilson MR, Gorman MP, DeRisi JL. ZSCAN1 Autoantibodies Are Associated with Pediatric Paraneoplastic ROHHAD. Ann Neurol 2022; 92:279-291. [PMID: 35466441 PMCID: PMC9329235 DOI: 10.1002/ana.26380] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Rapid-onset Obesity with Hypothalamic Dysfunction, Hypoventilation and Autonomic Dysregulation (ROHHAD), is a severe pediatric disorder of uncertain etiology resulting in hypothalamic dysfunction and frequent sudden death. Frequent co-occurrence of neuroblastic tumors have fueled suspicion of an autoimmune paraneoplastic neurological syndrome (PNS); however, specific anti-neural autoantibodies, a hallmark of PNS, have not been identified. Our objective is to determine if an autoimmune paraneoplastic etiology underlies ROHHAD. METHODS Immunoglobulin G (IgG) from pediatric ROHHAD patients (n = 9), non-inflammatory individuals (n = 100) and relevant pediatric controls (n = 25) was screened using a programmable phage display of the human peptidome (PhIP-Seq). Putative ROHHAD-specific autoantibodies were orthogonally validated using radioactive ligand binding and cell-based assays. Expression of autoantibody targets in ROHHAD tumor and healthy brain tissue was assessed with immunohistochemistry and mass spectrometry, respectively. RESULTS Autoantibodies to ZSCAN1 were detected in ROHHAD patients by PhIP-Seq and orthogonally validated in 7/9 ROHHAD patients and 0/125 controls using radioactive ligand binding and cell-based assays. Expression of ZSCAN1 in ROHHAD tumor and healthy human brain tissue was confirmed. INTERPRETATION Our results support the notion that tumor-associated ROHHAD syndrome is a pediatric PNS, potentially initiated by an immune response to peripheral neuroblastic tumor. ZSCAN1 autoantibodies may aid in earlier, accurate diagnosis of ROHHAD syndrome, thus providing a means toward early detection and treatment. This work warrants follow-up studies to test sensitivity and specificity of a novel diagnostic test. Last, given the absence of the ZSCAN1 gene in rodents, our study highlights the value of human-based approaches for detecting novel PNS subtypes. ANN NEUROL 2022;92:279-291.
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Affiliation(s)
- Caleigh Mandel‐Brehm
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | | | - Baouyen Tran
- Weill Institute for Neurosciences, Department of NeurologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Andrew F. Kung
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Sabrina A. Mann
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Sara E. Vazquez
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Hanna Retallack
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Hannah A. Sample
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Kelsey C. Zorn
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Lillian M. Khan
- Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
| | - Lauren M. Kerr
- Department of NeurologyBoston Children's HospitalBostonMAUSA
| | - Patrick L. McAlpine
- Otolaryngology Head and Neck Surgery Research DivisionStanford UniversityStanfordCAUSA
| | | | | | | | - Umakanth Katwa
- Department of Pulmonary MedicineSleep Center, Boston Children's HospitalBostonMAUSA
| | - Christina M. Astley
- Division of Endocrinology & Computational EpidemiologyBoston Children's HospitalBostonMAUSA
| | - Stuart Tomko
- Department of NeurologyWashington UniversitySt. LouisMOUSA
| | - Josep Dalmau
- Catalan Institution for Research and Advanced Studies (ICREA), Hospital Clinic‐IdibapsUniversity of BarcelonaBarcelonaSpain
| | - William W. Seeley
- Memory and Aging Center, Department of NeurologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Samuel J. Pleasure
- Weill Institute for Neurosciences, Department of NeurologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Michael R. Wilson
- MAS, Weill Institute for Neurosciences, Department of NeurologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Mark P. Gorman
- Department of NeurologyHarvard Medical SchoolBostonMAUSA
| | - Joseph L. DeRisi
- Chan Zuckerberg Biohub, Department of Biochemistry and BiophysicsUniversity of CaliforniaSan FranciscoCAUSA
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8
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Mo A, Donatelli S, Benson LA, Lee PY, Rivkin MJ. Child Neurology: Recurrent Brainstem Strokes and Aphthous Ulcers in a Child With Mutations in the ADA2 Gene. Neurology 2021; 97:696-699. [PMID: 34039731 DOI: 10.1212/wnl.0000000000012271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Alisa Mo
- From the Department of Neurology (A.M., S.D., L.A.B., M.J.R.), Department of Pediatrics, Division of Immunology (P.Y.L.), Department of Psychiatry (M.J.R., P.Y.L.), and Department of Radiology (M.J.R., P.Y.L.), Boston Children's Hospital; and Departments of Neurology (L.A.B., M.J.R., P.Y.L.) and Pediatrics (P.Y.L.), Harvard Medical School, Boston, MA
| | - Stephanie Donatelli
- From the Department of Neurology (A.M., S.D., L.A.B., M.J.R.), Department of Pediatrics, Division of Immunology (P.Y.L.), Department of Psychiatry (M.J.R., P.Y.L.), and Department of Radiology (M.J.R., P.Y.L.), Boston Children's Hospital; and Departments of Neurology (L.A.B., M.J.R., P.Y.L.) and Pediatrics (P.Y.L.), Harvard Medical School, Boston, MA
| | - Leslie A Benson
- From the Department of Neurology (A.M., S.D., L.A.B., M.J.R.), Department of Pediatrics, Division of Immunology (P.Y.L.), Department of Psychiatry (M.J.R., P.Y.L.), and Department of Radiology (M.J.R., P.Y.L.), Boston Children's Hospital; and Departments of Neurology (L.A.B., M.J.R., P.Y.L.) and Pediatrics (P.Y.L.), Harvard Medical School, Boston, MA
| | - Pui Y Lee
- From the Department of Neurology (A.M., S.D., L.A.B., M.J.R.), Department of Pediatrics, Division of Immunology (P.Y.L.), Department of Psychiatry (M.J.R., P.Y.L.), and Department of Radiology (M.J.R., P.Y.L.), Boston Children's Hospital; and Departments of Neurology (L.A.B., M.J.R., P.Y.L.) and Pediatrics (P.Y.L.), Harvard Medical School, Boston, MA
| | - Michael J Rivkin
- From the Department of Neurology (A.M., S.D., L.A.B., M.J.R.), Department of Pediatrics, Division of Immunology (P.Y.L.), Department of Psychiatry (M.J.R., P.Y.L.), and Department of Radiology (M.J.R., P.Y.L.), Boston Children's Hospital; and Departments of Neurology (L.A.B., M.J.R., P.Y.L.) and Pediatrics (P.Y.L.), Harvard Medical School, Boston, MA.
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Horton MK, McCauley K, Fadrosh D, Fujimura K, Graves J, Ness J, Wheeler Y, Gorman MP, Benson LA, Weinstock‐Guttman B, Waldman A, Rodriguez M, Tillema J, Krupp L, Belman A, Mar S, Rensel M, Chitnis T, Casper TC, Rose J, Hart J, Shao X, Tremlett H, Lynch SV, Barcellos LF, Waubant E. Gut microbiome is associated with multiple sclerosis activity in children. Ann Clin Transl Neurol 2021; 8:1867-1883. [PMID: 34409759 PMCID: PMC8419410 DOI: 10.1002/acn3.51441] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To identify features of the gut microbiome associated with multiple sclerosis activity over time. METHODS We used 16S ribosomal RNA sequencing from stool of 55 recently diagnosed pediatric-onset multiple sclerosis patients. Microbiome features included the abundance of individual microbes and networks identified from weighted genetic correlation network analyses. Prentice-Williams-Peterson Cox proportional hazards models estimated the associations between features and three disease activity outcomes: clinical relapses and both new/enlarging T2 lesions and new gadolinium-enhancing lesions on brain MRI. Analyses were adjusted for age, sex, and disease-modifying therapies. RESULTS Participants were followed, on average, 2.1 years. Five microbes were nominally associated with all three disease activity outcomes after multiple testing correction. These included butyrate producers Odoribacter (relapse hazard ratio = 0.46, 95% confidence interval: 0.24, 0.88) and Butyricicoccus (relapse hazard ratio = 0.49, 95% confidence interval: 0.28, 0.88). Two networks of co-occurring gut microbes were significantly associated with a higher hazard of both MRI outcomes (gadolinium-enhancing lesion hazard ratios (95% confidence intervals) for Modules 32 and 33 were 1.29 (1.08, 1.54) and 1.42 (1.18, 1.71), respectively; T2 lesion hazard ratios (95% confidence intervals) for Modules 32 and 33 were 1.34 (1.15, 1.56) and 1.41 (1.21, 1.64), respectively). Metagenomic predictions of these networks demonstrated enrichment for amino acid biosynthesis pathways. INTERPRETATION Both individual and networks of gut microbes were associated with longitudinal multiple sclerosis activity. Known functions and metagenomic predictions of these microbes suggest the important role of butyrate and amino acid biosynthesis pathways. This provides strong support for future development of personalized microbiome interventions to modify multiple sclerosis disease activity.
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Affiliation(s)
- Mary K. Horton
- Division of EpidemiologyUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Kathryn McCauley
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Douglas Fadrosh
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Kei Fujimura
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Jennifer Graves
- Department of NeurosciencesUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Jayne Ness
- Division of Pediatric NeurologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Yolanda Wheeler
- Division of Pediatric NeurologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Mark P. Gorman
- Department of NeurologyBoston Children’s HospitalBostonMassachusettsUSA
| | - Leslie A. Benson
- Department of NeurologyBoston Children’s HospitalBostonMassachusettsUSA
| | | | - Amy Waldman
- Department of NeurologyChildren’s Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | | | | | - Lauren Krupp
- Pediatric Multiple Sclerosis CenterNew York University Langone Medical CenterNew YorkNew YorkUSA
| | - Anita Belman
- Pediatric Multiple Sclerosis CenterNew York University Langone Medical CenterNew YorkNew YorkUSA
| | - Soe Mar
- Department of NeurologyWashington University in St. LouisSt. LouisMissouriUSA
| | - Mary Rensel
- Department of NeurologyCleveland ClinicClevelandOhioUSA
| | - Tanuja Chitnis
- Division of Child NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | | | - John Rose
- School of MedicineUniversity of Utah SchoolSalt Lake CityUtahUSA
| | - Janace Hart
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Xiaorong Shao
- Division of EpidemiologyUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Helen Tremlett
- Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Susan V. Lynch
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Lisa F. Barcellos
- Division of EpidemiologyUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Emmanuelle Waubant
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
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10
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Greenberg BM, Casper TC, Mar SS, Ness JM, Plumb P, Liang S, Goyal M, Weinstock-Guttman B, Rodriguez M, Aaen GS, Belman A, Barcellos LF, Rose JW, Gorman MP, Benson LA, Candee M, Chitnis T, Harris YC, Kahn IL, Roalstad S, Hart J, Lotze TE, Rensel M, Rubin JP, Schreiner TL, Tillema JM, Waldman AT, Krupp L, Graves J, Drake K, Waubant E. Familial History of Autoimmune Disorders Among Patients With Pediatric Multiple Sclerosis. Neurol Neuroimmunol Neuroinflamm 2021; 8:e1049. [PMID: 34353894 PMCID: PMC8362349 DOI: 10.1212/nxi.0000000000001049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 06/17/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVE The objective of this study was to determine whether family members of patients with pediatric multiple sclerosis (MS) have an increased prevalence of autoimmune conditions compared with controls. METHODS Data collected during a pediatric MS case-control study of risk factors included information about various autoimmune diseases in family members. The frequency of these disorders was compared between cases and controls. RESULTS There was an increased rate of autoimmune diseases among family members of pediatric MS cases compared with controls with first-degree history of MS excluded (OR = 2.27, 95% CI 1.71-3.01, p < 0.001). There was an increased rate of MS among second-degree relatives of pediatric MS cases compared with controls (OR = 3.47, 95% CI 1.36-8.86, p = 0.009). The OR for MS was 2.64 when restricted to maternal relatives and 6.37 when restricted to paternal relatives. DISCUSSION The increased rates of autoimmune disorders, including thyroid disorders and MS among families of patients with pediatric MS, suggest shared genetic factors among families with children diagnosed with pediatric MS.
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Affiliation(s)
- Benjamin M. Greenberg
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Theron Charles Casper
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Soe S. Mar
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Jayne M. Ness
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Patricia Plumb
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Shannon Liang
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Manu Goyal
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Bianca Weinstock-Guttman
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Moses Rodriguez
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Gregory S. Aaen
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Anita Belman
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Lisa F. Barcellos
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - John W. Rose
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Mark P. Gorman
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Leslie A. Benson
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Meghan Candee
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Tanuja Chitnis
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Yolanda C. Harris
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Ilana L. Kahn
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Shelly Roalstad
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Janace Hart
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Timothy E. Lotze
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Mary Rensel
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Jennifer P. Rubin
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Teri L. Schreiner
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Jan-Mendelt Tillema
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Amy Tara Waldman
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Lauren Krupp
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Jennifer Graves
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Kaylea Drake
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Emmanuelle Waubant
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
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11
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Sguigna PV, McCreary MC, Conger DL, Graves JS, Benson LA, Waldman AT, Greenberg BM. Utilization of Visual Acuity Retroilluminated Charts for the Assessment of Afferent Visual System Dysfunction in a Pediatric Neuroimmunology Population. J Neuroophthalmol 2021; 41:19-23. [PMID: 32868561 DOI: 10.1097/wno.0000000000001001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Visual acuity has been a significant outcome measure in clinical trials for patients suffering from neuro-ophthalmological diseases and multiple sclerosis; however, there are limited data on the comparison of various testing strategies in pediatric patients with these disorders. Clinical trials using vision as an outcome could include a variety of tools to assess the acuity, including 2-m and 4-m standardized retroilluminated charts. METHODS We investigated the difference in Early Treatment Diabetic Retinopathy Study (ETDRS) scores obtained using 2-m and 4-m charts, as well as the impact of optic neuritis, use of vision correction, age, and gender on visual acuity data from 71 patients with pediatric neuroimmunological conditions in a cross-sectional study. RESULTS We determine that the ETDRS letter scores obtained using 4-m charts are on average 3.43 points less (P = 0.0034) when testing monocular ETDRS letter scores and on average 4.14 points less (P = 0.0008) when testing binocular ETDRS letter scores, relative to that obtained using the 2-m charts. However, we find that when performing monocular testing, optic neuritis in the eye being tested did not result in a statistically significant difference between 2-m and 4-m ETDRS letter scores. CONCLUSIONS Although visual acuity charts are formatted by the distance, there are significant differences in the number of letters correctly identified between 2-m and 4-m charts. Although the differences may not impact the clinical acuity, research protocols should consider these differences before collapsing data across disparate studies.
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Affiliation(s)
- Peter V Sguigna
- Multiple Sclerosis Division (PVS, MM, DC, BMG), Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas, Texas; Department of Neurology (JG), University of California San Diego, San Diego, California; Department of Neurology and Pediatrics (LB), Boston Children's Hospital, Boston, Massachusetts; Division of Neurology (ATW), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Departments of Neurology and Pediatrics (ATW), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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12
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Solomon IH, Li H, Benson LA, Henderson LA, Degar BA, Gorman MP, Duncan CN, Lidov HG, Alexandrescu S. Histopathologic Correlates of Familial Hemophagocytic Lymphohistiocytosis Isolated to the Central Nervous System. J Neuropathol Exp Neurol 2019; 77:1079-1084. [PMID: 30295794 DOI: 10.1093/jnen/nly094] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/12/2018] [Indexed: 01/14/2023] Open
Abstract
Familial hemophagocytic lymphohistiocytosis (HLH) is an immune hyperactivation syndrome caused by mutations in genes associated with cytotoxic T-cell and NK-cell function. While neurological manifestations frequently accompany systemic inflammation at initial presentation, isolated central nervous system (CNS) involvement is rare, and the histological correlates are not well described. We present 3 patients (ages 5, 6, and 7 years) with CNS-isolated familial HLH, who presented with a variety of neurological symptoms and underwent brain biopsies for multifocal enhancing supratentorial and infratentorial lesions. Biopsy slides from all 3 patients revealed similar findings: perivascular lymphocytes, predominantly CD3+ T-cells (CD4>CD8) with occasional intramural infiltration of small vessels; scattered histiocytes without hemophagocytosis; parenchymal and leptomeningeal inflammation varying from mild and focal to severe and sheet-like with associated destructive lesions. There was no evidence of demyelination, neoplasia, or infection. Genetic testing identified compound heterozygous mutations in PRF1 (Patients 1 and 2) and UNC13D (Patient 3), with no evidence of systemic disease except decreased NK-cell function. All 3 patients were treated with hematopoietic stem cell transplantation with marked improvement of symptoms. These findings combined with the poor outcomes associated with delayed diagnosis and lack of aggressive treatment highlight the need to consider HLH in the differential diagnosis of inflammatory brain lesions.
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Affiliation(s)
- Isaac H Solomon
- Departments of Pathology, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hojun Li
- Departments of Pathology, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Leslie A Benson
- Departments of Pathology, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lauren A Henderson
- Departments of Pathology, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Immunology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Barbara A Degar
- Departments of Pathology, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Mark P Gorman
- Departments of Pathology, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christine N Duncan
- Departments of Pathology, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Immunology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hart G Lidov
- Departments of Pathology, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sanda Alexandrescu
- Departments of Pathology, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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13
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Benson LA, Li H, Henderson LA, Solomon IH, Soldatos A, Murphy J, Bielekova B, Kennedy AL, Rivkin MJ, Davies KJ, Hsu AP, Holland SM, Gahl WA, Sundel RP, Lehmann LE, Lee MA, Alexandrescu S, Degar BA, Duncan CN, Gorman MP. Pediatric CNS-isolated hemophagocytic lymphohistiocytosis. Neurol Neuroimmunol Neuroinflamm 2019; 6:e560. [PMID: 31044148 PMCID: PMC6467688 DOI: 10.1212/nxi.0000000000000560] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/15/2019] [Indexed: 11/15/2022]
Abstract
Objective To highlight a novel, treatable syndrome, we report 4 patients with CNS-isolated inflammation associated with familial hemophagocytic lymphohistiocytosis (FHL) gene mutations (CNS-FHL). Methods Retrospective chart review. Results Patients with CNS-FHL are characterized by chronic inflammation restricted to the CNS that is not attributable to any previously described neuroinflammatory etiology and have germline mutations in known FHL-associated genes with no signs of systemic inflammation. Hematopoietic stem cell transplantation (HCT) can be well tolerated and effective in achieving or maintaining disease remission in patients with CNS-FHL. Conclusions Early and accurate diagnosis followed by treatment with HCT can reduce morbidity and mortality in CNS-FHL, a novel, treatable syndrome. Classification of evidence This study provides Class IV evidence that HCT is well tolerated and effective in treating CNS-FHL.
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Affiliation(s)
- Leslie A Benson
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Hojun Li
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Lauren A Henderson
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Isaac H Solomon
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Ariane Soldatos
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Jennifer Murphy
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Bibiana Bielekova
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Alyssa L Kennedy
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Michael J Rivkin
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Kimberly J Davies
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Amy P Hsu
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Steven M Holland
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - William A Gahl
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Robert P Sundel
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Leslie E Lehmann
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Michelle A Lee
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Sanda Alexandrescu
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Barbara A Degar
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Christine N Duncan
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
| | - Mark P Gorman
- Department of Neurology (L.A.B., M.J.R., M.P.G.), Boston Children's Hospital; Dana-Farber/Boston Children's Cancer and Blood Disorders Center (H.L., A.L.K., L.E.L., B.A.D., C.N.D.); Department of Rheumatology (L.A.H., R.P.S.), Boston Children's Hospital; Department of Pathology (I.H.S002E, S.A.), Boston Children's Hospital, Boston, MA; Undiagnosed Diseases Program (A.S., J.M., W.A.G.), National Human Genome Research Institute; Neuroimmunological Diseases Section (B.B.), Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases; Laboratory of Clinical Immunology and Microbiology (A.P.H., S.M.H.), National Institute of Allergy and Infectious Diseases, Bethesda, MD; and Division of Hematology, Oncology (M.L.A.), and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, NY
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14
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Halyabar O, Chang MH, Schoettler ML, Schwartz MA, Baris EH, Benson LA, Biggs CM, Gorman M, Lehmann L, Lo MS, Nigrovic PA, Platt CD, Priebe GP, Rowe J, Sundel RP, Surana NK, Weinacht KG, Mann A, Yuen JC, Meleedy-Rey P, Starmer A, Banerjee T, Dedeoglu F, Degar BA, Hazen MM, Henderson LA. Calm in the midst of cytokine storm: a collaborative approach to the diagnosis and treatment of hemophagocytic lymphohistiocytosis and macrophage activation syndrome. Pediatr Rheumatol Online J 2019; 17:7. [PMID: 30764840 PMCID: PMC6376762 DOI: 10.1186/s12969-019-0309-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 02/04/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) were historically thought to be distinct entities, often managed in isolation. In fact, these conditions are closely related. A collaborative approach, which incorporates expertise from subspecialties that previously treated HLH/MAS independently, is needed. We leveraged quality improvement (QI) techniques in the form of an Evidence-Based Guideline (EBG) to build consensus across disciplines on the diagnosis and treatment of HLH/MAS. METHODS A multidisciplinary work group was convened that met monthly to develop the HLH/MAS EBG. Literature review and expert opinion were used to develop a management strategy for HLH/MAS. The EBG was implemented, and quality metrics were selected to monitor outcomes. RESULTS An HLH/MAS clinical team was formed with representatives from subspecialties involved in the care of patients with HLH/MAS. Broad entry criteria for the HLH/MAS EBG were established and included fever and ferritin ≥500 ng/mL. The rheumatology team was identified as the "gate-keeper," charged with overseeing the diagnostic evaluation recommended in the EBG. First-line medications were recommended based on the acuity of illness and risk of concurrent infection. Quality metrics to be tracked prospectively based on time to initiation of treatment and clinical response were selected. CONCLUSION HLH/MAS are increasingly considered to be a spectrum of related conditions, and joint management across subspecialties could improve patient outcomes. Our experience in creating a multidisciplinary approach to HLH/MAS management can serve as a model for care at other institutions.
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Affiliation(s)
- Olha Halyabar
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Margaret H. Chang
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0004 0378 8294grid.62560.37Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Boston, MA USA
| | - Michelle L. Schoettler
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Marc A. Schwartz
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Ezgi H. Baris
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0001 0668 8422grid.16477.33Department of Pediatrics, Marmara University Pendik Research and Training Hospital, Istanbul, Turkey
| | - Leslie A. Benson
- 0000 0004 0378 8438grid.2515.3Department of Neurology, Boston Children’s Hospital, Boston, MA USA
| | - Catherine M. Biggs
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2288 9830grid.17091.3eDepartment of Pediatrics, British Columbia Children’s Hospital, University of British Columbia, Vancouver, BC Canada
| | - Mark Gorman
- 0000 0004 0378 8438grid.2515.3Department of Neurology, Boston Children’s Hospital, Boston, MA USA
| | - Leslie Lehmann
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Mindy S. Lo
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Peter A. Nigrovic
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0004 0378 8294grid.62560.37Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Boston, MA USA
| | - Craig D. Platt
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Gregory P. Priebe
- 0000 0004 0378 8438grid.2515.3Division of Critical Care Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Jared Rowe
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Robert P. Sundel
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Neeraj K. Surana
- 0000 0004 0378 8438grid.2515.3Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA USA ,0000 0004 1936 7961grid.26009.3dDepartment of Pediatrics, Duke University, Durham, NC USA
| | - Katja G. Weinacht
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA ,0000 0004 0450 875Xgrid.414123.1Division of Stem Cell Transplantation and Regenerative Medicine, Lucile Packard Children’s Hospital Stanford, Stanford, CA USA
| | - Alison Mann
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Jenny Chan Yuen
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Patricia Meleedy-Rey
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Amy Starmer
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Taruna Banerjee
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Fatma Dedeoglu
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Barbara A. Degar
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Melissa M. Hazen
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Lauren A. Henderson
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
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15
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Elrick MJ, Gordon-Lipkin E, Crawford TO, Van Haren K, Messacar K, Thornton N, Dee E, Voskertchian A, Nance JR, Muñoz LS, Gorman MP, Benson LA, Thomas DL, Pardo CA, Milstone AM, Duggal P. Clinical Subpopulations in a Sample of North American Children Diagnosed With Acute Flaccid Myelitis, 2012-2016. JAMA Pediatr 2019; 173:134-139. [PMID: 30500056 PMCID: PMC6439600 DOI: 10.1001/jamapediatrics.2018.4890] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Acute flaccid myelitis (AFM) is an emerging poliolike illness of children whose clinical spectrum and associated pathogens are only partially described. The case definition is intentionally encompassing for epidemiologic surveillance to capture all potential AFM cases. Defining a restrictive, homogenous subpopulation may aid our understanding of this emerging disease. OBJECTIVE To evaluate the extent to which the US Centers for Disease Control and Prevention (CDC) case definition of AFM incorporates possible alternative diagnoses and to assess the plausibility of a case definition that enriches the biological homogeneity of AFM for inclusion in research studies. DESIGN, SETTING, AND PARTICIPANTS Retrospective case analysis of children younger than 18 years diagnosed as having AFM between 2012 and 2016 using the CDC case definition. Group 1 included patients recruited from the United States and Canada based on the CDC case definition of AFM. Group 2 included patients referred to the Johns Hopkins Transverse Myelitis Center for evaluation of suspected AFM. Patients' records and imaging data were critically reviewed by 3 neurologists to identify those cases with definable alternative diagnoses, and the remaining patients were categorized as having restrictively defined AFM (rAFM). Clinical characteristics were compared between patients with rAFM (cases) and those with alternative diagnoses, and a case description distinguishing these AFM groups was identified. Interrater reliability of this description was confirmed for a subset of cases by a fourth neurologist. Data were analyzed between May 2017 and November 2018. MAIN OUTCOMES AND MEASURES Proportion of patients with possible alternative diagnosis. RESULTS Of the 45 patients who met the CDC AFM case definition and were included, the mean age was 6.1 years; 27 were boys (60%); and 37 were white (82%), 3 were Asian (7%), 1 was Hispanic (2%), and 4 were mixed race/ethnicity (9%). Of the included patients, 34 were classified as having rAFM, and 11 had alternate diagnoses (including transverse myelitis, other demyelinating syndromes, spinal cord stroke, Guillain-Barre syndrome, Chiari I myelopathy, and meningitis). Factors differing between groups were primarily asymmetry of weakness, lower motor neuron signs, preceding viral syndrome, symptoms evolving over hours to days, absence of sensory deficits, and magnetic resonance imaging findings. A case description was able to reliably define the rAFM group. CONCLUSIONS AND RELEVANCE We present an approach for defining a homogeneous research population that may more accurately reflect the pathogenesis of the prototypical poliomyelitis-like subgroup of AFM. The definition of rAFM forms a blueprint for inclusion criteria in future research efforts, but more work is required for refinement and external validation.
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Affiliation(s)
- Matthew J. Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Thomas O. Crawford
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Keith Van Haren
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Kevin Messacar
- Department of Pediatrics, Children’s Hospital Colorado, the University of Colorado, Aurora
| | - Nicole Thornton
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth Dee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Annie Voskertchian
- Division of Infectious Disease, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jessica R. Nance
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura S. Muñoz
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark P. Gorman
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Leslie A. Benson
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - David L. Thomas
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carlos A. Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aaron M. Milstone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,Division of Infectious Disease, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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16
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Messacar K, Sillau S, Hopkins SE, Otten C, Wilson-Murphy M, Wong B, Santoro JD, Treister A, Bains HK, Torres A, Zabrocki L, Glanternik JR, Hurst AL, Martin JA, Schreiner T, Makhani N, DeBiasi RL, Kruer MC, Tremoulet AH, Van Haren K, Desai J, Benson LA, Gorman MP, Abzug MJ, Tyler KL, Dominguez SR. Safety, tolerability, and efficacy of fluoxetine as an antiviral for acute flaccid myelitis. Neurology 2018; 92:e2118-e2126. [PMID: 30413631 DOI: 10.1212/wnl.0000000000006670] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/10/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To determine the safety, tolerability, and efficacy of fluoxetine for proven or presumptive enterovirus (EV) D68-associated acute flaccid myelitis (AFM). METHODS A multicenter cohort study of US patients with AFM in 2015-2016 compared serious adverse events (SAEs), adverse effects, and outcomes between fluoxetine-treated patients and untreated controls. Fluoxetine was administered at the discretion of treating providers with data gathered retrospectively. The primary outcome was change in summative limb strength score (SLSS; sum of Medical Research Council strength in all 4 limbs, ranging from 20 [normal strength] to 0 [complete quadriparesis]) between initial examination and latest follow-up, with increased SLSS reflecting improvement and decreased SLSS reflecting worsened strength. RESULTS Fifty-six patients with AFM from 12 centers met study criteria. Among 30 patients exposed to fluoxetine, no SAEs were reported and adverse effect rates were similar to unexposed patients (47% vs 65%, p = 0.16). The 28 patients treated with >1 dose of fluoxetine were more likely to have EV-D68 identified (57.1% vs 14.3%, p < 0.001). Their SLSS was similar at initial examination (mean SLSS 12.9 vs 14.3, p = 0.31) but lower at nadir (mean SLSS 9.25 vs 12.82, p = 0.02) and latest follow-up (mean SLSS 12.5 vs 16.4, p = 0.005) compared with the 28 patients receiving 1 (n = 2) or no (n = 26) doses. In propensity-adjusted analysis, SLSS from initial examination to latest follow-up decreased by 0.2 (95% confidence interval [CI] -1.8 to +1.4) in fluoxetine-treated patients and increased by 2.5 (95% CI +0.7 to +4.4) in untreated patients (p = 0.015). CONCLUSION Fluoxetine was well-tolerated. Fluoxetine was preferentially given to patients with AFM with EV-D68 identified and more severe paralysis at nadir, who ultimately had poorer long-term outcomes. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with EV-D68-associated AFM, fluoxetine is well-tolerated and not associated with improved neurologic outcomes.
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Affiliation(s)
- Kevin Messacar
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC.
| | - Stefan Sillau
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Sarah E Hopkins
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Catherine Otten
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Molly Wilson-Murphy
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Brian Wong
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Jonathan D Santoro
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Andrew Treister
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Harlori K Bains
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Alcy Torres
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Luke Zabrocki
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Julia R Glanternik
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Amanda L Hurst
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Jan A Martin
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Teri Schreiner
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Naila Makhani
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Roberta L DeBiasi
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Michael C Kruer
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Adriana H Tremoulet
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Keith Van Haren
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Jay Desai
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Leslie A Benson
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Mark P Gorman
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Mark J Abzug
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Kenneth L Tyler
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
| | - Samuel R Dominguez
- From the Departments of Pediatrics (K.M., J.A.M., T.S., M.J.A., S.R.D.) and Neurology (K.M., S.S., J.A.M., T.S., K.L.T.), University of Colorado School of Medicine; Children's Hospital Colorado (K.M., A.L.H., J.A.M., T.S., M.J.A., S.R.D.), Aurora; Children's Hospital of Philadelphia (S.E.H.), PA; Seattle Children's Hospital (C.O.), University of Washington; Boston Children's Hospital (M.W.-M., L.A.B., M.P.G.), MA; Children's Hospital of Los Angeles (B.W., J.D.), CA; Stanford University (J.D.S., K.V.H.), Palo Alto, CA; University of California San Diego (A.T., A.H.T.); Phoenix Children's Hospital (H.K.B., M.C.K.), AZ; Boston Medical Center (A.T.), MA; Naval Medical Center of San Diego (L.Z.), CA; Departments of Pediatrics (J.R.G., N.M.) and Neurology (N.M.), Yale School of Medicine, New Haven, CT; and Children's National Medical Center (R.L.D.), Washington, DC
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Abstract
Optic neuritis (ON) is a common presenting symptom in pediatric CNS demyelinating disorders and may be associated with dramatic visual loss. Knowledge regarding clinical presentation, associated diseases, therapy, and outcomes in ON in children has grown over the past decade. These studies have shown that younger children (<10 years of age) are more likely to present with bilateral ON and older children with unilateral ON. Furthermore, studies focusing on visual recovery have shown excellent recovery of high-contrast visual acuity in the majority of children, but functional and structural studies have shown evidence of irreversible injury and functional decline after ON in children. Although randomized controlled treatment trials have not been performed in children and adolescents with ON, standard of care suggests that the use of high-dose pulse steroids is safe and likely effective. This article reviews current knowledge about the clinical presentation and management of pediatric ON, with attention to associated syndromes and evaluative tools that may inform diagnosis and interventions.
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Affiliation(s)
- E Ann Yeh
- From the Division of Neurology (E.A.Y.), Hospital for Sick Children, Hospital for Sick Children Research Institute, Department of Pediatrics, University of Toronto, Ontario, Canada; Department of Neurology (J.S.G.), University of California, San Francisco; Department of Neurology (L.A.B.), Boston Children's Hospital, Boston, MA; Department of Neurology (E.W.), Birmingham Children's Hospital, Birmingham, UK; and Department of Neurology (A.W.), The Children's Hospital of Philadelphia, PA.
| | - Jennifer S Graves
- From the Division of Neurology (E.A.Y.), Hospital for Sick Children, Hospital for Sick Children Research Institute, Department of Pediatrics, University of Toronto, Ontario, Canada; Department of Neurology (J.S.G.), University of California, San Francisco; Department of Neurology (L.A.B.), Boston Children's Hospital, Boston, MA; Department of Neurology (E.W.), Birmingham Children's Hospital, Birmingham, UK; and Department of Neurology (A.W.), The Children's Hospital of Philadelphia, PA
| | - Leslie A Benson
- From the Division of Neurology (E.A.Y.), Hospital for Sick Children, Hospital for Sick Children Research Institute, Department of Pediatrics, University of Toronto, Ontario, Canada; Department of Neurology (J.S.G.), University of California, San Francisco; Department of Neurology (L.A.B.), Boston Children's Hospital, Boston, MA; Department of Neurology (E.W.), Birmingham Children's Hospital, Birmingham, UK; and Department of Neurology (A.W.), The Children's Hospital of Philadelphia, PA
| | - Evangeline Wassmer
- From the Division of Neurology (E.A.Y.), Hospital for Sick Children, Hospital for Sick Children Research Institute, Department of Pediatrics, University of Toronto, Ontario, Canada; Department of Neurology (J.S.G.), University of California, San Francisco; Department of Neurology (L.A.B.), Boston Children's Hospital, Boston, MA; Department of Neurology (E.W.), Birmingham Children's Hospital, Birmingham, UK; and Department of Neurology (A.W.), The Children's Hospital of Philadelphia, PA
| | - Amy Waldman
- From the Division of Neurology (E.A.Y.), Hospital for Sick Children, Hospital for Sick Children Research Institute, Department of Pediatrics, University of Toronto, Ontario, Canada; Department of Neurology (J.S.G.), University of California, San Francisco; Department of Neurology (L.A.B.), Boston Children's Hospital, Boston, MA; Department of Neurology (E.W.), Birmingham Children's Hospital, Birmingham, UK; and Department of Neurology (A.W.), The Children's Hospital of Philadelphia, PA
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Nosadini M, Alper G, Riney CJ, Benson LA, Mohammad SS, Ramanathan S, Nolan M, Appleton R, Leventer RJ, Deiva K, Brilot F, Gorman MP, Waldman AT, Banwell B, Dale RC. Rituximab monitoring and redosing in pediatric neuromyelitis optica spectrum disorder. Neurol Neuroimmunol Neuroinflamm 2016; 3:e188. [PMID: 26819962 PMCID: PMC4723136 DOI: 10.1212/nxi.0000000000000188] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/29/2015] [Indexed: 01/01/2023]
Abstract
Objective: To study rituximab in pediatric neuromyelitis optica (NMO)/NMO spectrum disorders (NMOSD) and the relationship between rituximab, B cell repopulation, and relapses in order to improve rituximab monitoring and redosing. Methods: Multicenter retrospective study of 16 children with NMO/NMOSD receiving ≥2 rituximab courses. According to CD19 counts, events during rituximab were categorized as “repopulation,” “depletion,” or “depletion failure” relapses (repopulation threshold CD19 ≥10 × 106 cells/L). Results: The 16 patients (14 girls; mean age 9.6 years, range 1.8–15.3) had a mean of 6.1 events (range 1–11) during a mean follow-up of 6.1 years (range 1.6–13.6) and received a total of 76 rituximab courses (mean 4.7, range 2–9) in 42.6-year cohort treatment. Before rituximab, 62.5% had received azathioprine, mycophenolate mofetil, or cyclophosphamide. Mean time from rituximab to last documented B cell depletion and first repopulation was 4.5 and 6.8 months, respectively, with large interpatient variability. Earliest repopulations occurred with the lowest doses. Significant reduction between pre- and post-rituximab annualized relapse rate (ARR) was observed (p = 0.003). During rituximab, 6 patients were relapse-free, although 21 relapses occurred in 10 patients, including 13 “repopulation,” 3 “depletion,” and 4 “depletion failure” relapses. Of the 13 “repopulation” relapses, 4 had CD19 10–50 × 106 cells/L, 10 had inadequate monitoring (≤1 CD19 in the 4 months before relapses), and 5 had delayed redosing after repopulation detection. Conclusion: Rituximab is effective in relapse prevention, but B cell repopulation creates a risk of relapse. Redosing before B cell repopulation could reduce the relapse risk further. Classification of evidence: This study provides Class IV evidence that rituximab significantly reduces ARR in pediatric NMO/NMOSD. This study also demonstrates a relationship between B cell repopulation and relapses.
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Affiliation(s)
- Margherita Nosadini
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Gulay Alper
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Catherine J Riney
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Leslie A Benson
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Shekeeb S Mohammad
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Sudarshini Ramanathan
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Melinda Nolan
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Richard Appleton
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Richard J Leventer
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Kumaran Deiva
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Fabienne Brilot
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Mark P Gorman
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Amy T Waldman
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Brenda Banwell
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
| | - Russell C Dale
- Neuroimmunology Group (M. Nosadini, S.S.M., S.R., F.B., R.C.D.), Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Australia; Paediatric Neurology Unit (M. Nosadini), Department of Paediatrics, University of Padua, Italy; Clinical Neuroimmunology Program (G.A.), Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, PA; Neurology Department (C.J.R.), Lady Cilento Children's Hospital, University of Queensland, Australia; Pediatric Multiple Sclerosis and Related Diseases Program (L.A.B., M.P.G.), Boston Children's Hospital, Boston, MA; Department of Neurology (S.R.), Westmead Hospital, Sydney, Australia; Neurology Department (M. Nolan), Starship Children's Health, Auckland, New Zealand; The Roald Dahl EEG Unit (R.A.), Pediatric Neurosciences Foundation, Alder Hey Children's Hospital, Liverpool, UK; Department of Neurology (R.J.L.), Murdoch Childrens Research Institute and University of Melbourne Department of Paediatrics (R.J.L.), Royal Children's Hospital, Melbourne, Victoria, Australia; Assistance Publique-Hopitaux de Paris (K.D.), Hôpitaux Universitaires Paris-Sud, National Referral Center for Neuro-Inflammatory Diseases in Children (K.D.), Pediatric Neurology Department, and Université Paris-Sud (K.D.), Inserm U1012, Le Kremlin-Bicêtre, France; and Children's Hospital of Philadelphia (A.T.W., B.B.), University of Pennsylvania, Philadelphia
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Ramanathan S, Prelog K, Barnes EH, Tantsis EM, Reddel SW, Henderson APD, Vucic S, Gorman MP, Benson LA, Alper G, Riney CJ, Barnett M, Parratt JDE, Hardy TA, Leventer RJ, Merheb V, Nosadini M, Fung VSC, Brilot F, Dale RC. Radiological differentiation of optic neuritis with myelin oligodendrocyte glycoprotein antibodies, aquaporin-4 antibodies, and multiple sclerosis. Mult Scler 2015; 22:470-82. [PMID: 26163068 DOI: 10.1177/1352458515593406] [Citation(s) in RCA: 216] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/03/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recognizing the cause of optic neuritis (ON) affects treatment decisions and visual outcomes. OBJECTIVE We aimed to define radiological features of first-episode demyelinating ON. METHODS We performed blinded radiological assessment of 50 patients presenting with first-episode myelin oligodendrocyte glycoprotein (MOG) antibody-associated ON (MOG-ON; n=19), aquaporin-4 (AQP4) antibody-associated ON (AQP4-ON; n=11), multiple sclerosis (MS)-associated ON (MS-ON; n=13), and unclassified ON (n=7). RESULTS Bilateral involvement was more common in MOG-ON and AQP4-ON than MS-ON (84% vs. 82% vs. 23%), optic nerve head swelling was more common in MOG-ON (53% vs. 9% vs. 0%), chiasmal involvement was more common in AQP4-ON (5% vs. 64% vs. 15%), and bilateral optic tract involvement was more common in AQP4-ON (0% vs. 45% vs. 0%). Retrobulbar involvement was more common in MOG-ON, whereas intracranial involvement was more common in AQP4-ON. MOG-ON and AQP4-ON had longer lesion lengths than MS-ON. The combination of two predictors, the absence of magnetic resonance imaging brain abnormalities and a higher lesion extent score, showed a good ability to discriminate between an autoantibody-associated ON (MOG or AQP4) and MS. AQP4-ON more frequently had severe and sustained visual impairment. CONCLUSION MOG-ON and AQP4-ON are more commonly bilateral and longitudinally extensive. MOG-ON tends to involve the anterior optic pathway, whereas AQP4-ON the posterior optic pathway.
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Affiliation(s)
- Sudarshini Ramanathan
- Neuroimmunology group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at the Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, Australia/Department of Neurology, Westmead Hospital, and Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kristina Prelog
- Department of Medical Imaging, the Children's Hospital at Westmead, Sydney, Australia
| | | | - Esther M Tantsis
- Neuroimmunology group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at the Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Stephen W Reddel
- Department of Neurology, Concord Repatriation General Hospital, Sydney, Australia/Brain and Mind Research Institute, University of Sydney, Sydney, Australia
| | - Andrew P D Henderson
- Department of Neurology, Westmead Hospital, and Sydney Medical School, University of Sydney, Sydney, Australia/Department of Ophthalmology, Westmead Hospital, Sydney, Australia
| | - Steve Vucic
- Department of Neurology, Westmead Hospital, and Sydney Medical School, University of Sydney, Sydney, Australia/Western Clinical School, University of Sydney, Sydney, Australia
| | - Mark P Gorman
- Boston Children's Hospital, Boston, United States of America
| | - Leslie A Benson
- Boston Children's Hospital, Boston, United States of America
| | - Gulay Alper
- Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh, School of Medicine, Pittsburgh, United States of America
| | - Catherine J Riney
- Neurosciences Unit, Lady Cilento Children's Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Michael Barnett
- Brain and Mind Research Institute, University of Sydney, Sydney, Australia/Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - John D E Parratt
- Department of Neurology, Royal North Shore Hospital, Central Clinical School, University of Sydney, Sydney, Australia
| | - Todd A Hardy
- Brain and Mind Research Institute, University of Sydney, Sydney, Australia/Department of Neurology, Concord Repatriation General Hospital, Sydney, Australia
| | - Richard J Leventer
- Department of Neurology, University of Melbourne Department of Paediatrics, Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Australia
| | - Vera Merheb
- Neuroimmunology group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at the Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Margherita Nosadini
- Neuroimmunology group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at the Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Victor S C Fung
- Department of Neurology, Westmead Hospital, and Sydney Medical School, University of Sydney, Sydney, Australia
| | - Fabienne Brilot
- Neuroimmunology group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at the Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Russell C Dale
- Neuroimmunology group, Institute for Neuroscience and Muscle Research, The Kids Research Institute at the Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, Australia
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20
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Wan MJ, Adebona O, Benson LA, Gorman MP, Heidary G. Reply: To PMID 24907434. Am J Ophthalmol 2015; 159:211. [PMID: 25488651 DOI: 10.1016/j.ajo.2014.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/08/2014] [Indexed: 11/16/2022]
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Abstract
Autoimmunity is being increasingly recognized as a cause of neurologic presentations both inside and outside the intensive care unit (ICU) setting. Pediatric autoimmune neurologic diseases likely to be seen in the ICU include autoimmune encephalitidies such as N-Methyl-D-aspartate (NMDA) receptor encephalitis, central nervous system vasculitis, demyelinating disorders, and neurologic involvement of systemic autoimmune disorders. In addition, there are conditions of suspected autoimmune etiology such as febrile infection-related epilepsy syndrome (FIRES) and rapid-onset obesity, hypoventilation, hypothalamic dysfunction, and autonomic dysregulation (ROHHAD) syndrome that are rare, but when they do present, it is often to the ICU. Refractory seizures, altered mental status, and disordered breathing are the most common indications for intensive care for these patients.
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Affiliation(s)
- Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Boston, MA.
| | - Heather Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, Boston, MA
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22
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Wan MJ, Adebona O, Benson LA, Gorman MP, Heidary G. Visual outcomes in pediatric optic neuritis. Am J Ophthalmol 2014; 158:503-7.e2. [PMID: 24907434 DOI: 10.1016/j.ajo.2014.05.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/23/2014] [Accepted: 05/27/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE To describe the visual outcomes of a large cohort of pediatric patients presenting to a tertiary care pediatric hospital with first-episode optic neuritis. DESIGN Retrospective, observational cohort study. METHODS In a tertiary care pediatric hospital, patients with first-episode optic neuritis and at least 3 months of follow-up over a 10-year period were assessed and followed-up in the ophthalmology department. The main outcome measures were visual acuity at 3 months and 1 year of follow-up, with analysis of risk factors for poor visual outcomes and the time course of visual recovery. RESULTS Of the 59 pediatric patients with first-episode optic neuritis, 46 had at least 3 months of follow-up and 36 had at least 1 year of follow-up. The mean age was 12.6 years old; 72% were female, 41% had bilateral involvement, 52% had or developed an underlying diagnosis (39% multiple sclerosis, 7% acute disseminated encephalomyelitis, 7% neuromyelitis optica), and 91% received treatment (85% steroids, 7% multimodal). At 1 year, 81% were at least 20/20 and 89% were at least 20/40. A poor visual outcome at 1 year (<20/40) was associated with vision of <20/20 at 3 months (P = 0.041). Other clinical characteristics, including visual acuity at presentation, sex, bilateral involvement, optic nerve edema, and underlying diagnoses were not significantly associated with poor visual outcomes. CONCLUSIONS In this cohort of pediatric patients with optic neuritis, the majority of patients regained normal visual acuity at 1 year, regardless of baseline clinical characteristics.
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Affiliation(s)
- Michael J Wan
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Olumuyiwa Adebona
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gena Heidary
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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23
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Titulaer MJ, Höftberger R, Iizuka T, Leypoldt F, McCracken L, Cellucci T, Benson LA, Shu H, Irioka T, Hirano M, Singh G, Cobo Calvo A, Kaida K, Morales PS, Wirtz PW, Yamamoto T, Reindl M, Rosenfeld MR, Graus F, Saiz A, Dalmau J. Overlapping demyelinating syndromes and anti–N-methyl-D-aspartate receptor encephalitis. Ann Neurol 2014; 75:411-28. [PMID: 24700511 DOI: 10.1002/ana.24117] [Citation(s) in RCA: 337] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 02/03/2014] [Accepted: 02/03/2014] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To report the clinical, radiological, and immunological association of demyelinating disorders with anti–Nmethyl- D-aspartate receptor (NMDAR) encephalitis. METHODS Clinical and radiological analysis was done of a cohort of 691 patients with anti-NMDAR encephalitis. Determination of antibodies to NMDAR, aquaporin-4 (AQP4), and myelin oligodendrocyte glycoprotein (MOG) was performed using brain immunohistochemistry and cell-based assays. RESULTS Twenty-three of 691 patients with anti-NMDAR encephalitis had prominent magnetic resonance imaging (MRI) and/or clinical features of demyelination. Group 1 included 12 patients in whom anti-NMDAR encephalitis was preceded or followed by independent episodes of neuromyelitis optica (NMO) spectrum disorder (5 cases, 4 anti-AQP4 positive) or brainstem or multifocal demyelinating syndromes (7 cases, all anti-MOG positive). Group 2 included 11 patients in whom anti-NMDAR encephalitis occurred simultaneously with MRI and symptoms compatible with demyelination (5 AQ4 positive, 2 MOG positive). Group 3 (136 controls) included 50 randomly selected patients with typical anti-NMDAR encephalitis, 56 with NMO, and 30 with multiple sclerosis; NMDAR antibodies were detected only in the 50 anti-NMDAR patients, MOG antibodies in 3 of 50 anti-NMDAR and 1 of 56 NMO patients, and AQP4 antibodies in 48 of 56 NMO and 1 of 50 anti-NMDAR patients (p<0.0001 for all comparisons with Groups 1 and 2). Most patients improved with immunotherapy, but compared with anti-NMDAR encephalitis the demyelinating episodes required more intensive therapy and resulted in more residual deficits. Only 1 of 23 NMDAR patients with signs of demyelination had ovarian teratoma compared with 18 of 50 anti-NMDAR controls (p50.011). INTERPRETATION Patients with anti-NMDAR encephalitis may develop concurrent or separate episodes of demyelinating disorders, and conversely patients with NMO or demyelinating disorders with atypical symptoms (eg, dyskinesias, psychosis) may have anti-NMDAR encephalitis.
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24
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Malik MT, Healy BC, Benson LA, Kivisakk P, Musallam A, Weiner HL, Chitnis T. Factors associated with recovery from acute optic neuritis in patients with multiple sclerosis. Neurology 2014; 82:2173-9. [PMID: 24850491 DOI: 10.1212/wnl.0000000000000524] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To identify clinical and demographic features associated with the severity and recovery from acute optic neuritis (AON) episodes in patients with multiple sclerosis (MS). METHODS Adult (n = 253) and pediatric (n = 38) patients whose first symptom was AON were identified from our MS database. Severity measured by loss of visual acuity (mild attack ≤20/40, moderate attack 20/50-20/190, and severe attack ≥20/200) and recovery in visual acuity at 1 year after the attack (complete recovery ≤20/20, fair recovery 20/40, and poor recovery ≥20/50) were recorded. Demographic and clinical features associated with attack severity and recovery were identified using proportional odds logistic regression. For another group of patients, blood samples were available within 6 months of an AON attack. In this group, the impact of vitamin D level on the severity/recovery was also assessed. RESULTS Men (adjusted odds ratio [OR] = 2.28, p = 0.03) and subjects with severe attacks (adjusted OR = 5.24, p < 0.001) had worse recovery. AON severity was similar between the pediatric and adult subjects, but recovery was significantly better in pediatric subjects in the unadjusted analysis (p = 0.041) and the analysis adjusted for sex (p = 0.029). Season-adjusted vitamin D level was significantly associated with attack severity (OR for 10-U increase in vitamin D level = 0.47; 95% confidence interval: 0.32, 0.68; p < 0.001). Vitamin D level was not associated with recovery from the attack (p = 0.98) in univariate analysis or after accounting for attack severity (p = 0.10). CONCLUSION Vitamin D levels affect AON severity, whereas younger age, attack severity, and male sex affect AON recovery. Underlying mechanisms and potential therapeutic targets may identify new measures to mitigate disability accrual in MS.
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Affiliation(s)
- Muhammad Taimur Malik
- From the Partners Multiple Sclerosis Center (M.T.M., B.C.H., L.A.B., A.M., H.L.W., T.C.) and Center for Neurological Diseases (P.K., H.L.W., T.C.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (L.A.B.), Boston Children's Hospital; and Partners Pediatric Multiple Sclerosis Center (L.A.B., T.C.), Massachusetts General Hospital, Boston
| | - Brian C Healy
- From the Partners Multiple Sclerosis Center (M.T.M., B.C.H., L.A.B., A.M., H.L.W., T.C.) and Center for Neurological Diseases (P.K., H.L.W., T.C.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (L.A.B.), Boston Children's Hospital; and Partners Pediatric Multiple Sclerosis Center (L.A.B., T.C.), Massachusetts General Hospital, Boston
| | - Leslie A Benson
- From the Partners Multiple Sclerosis Center (M.T.M., B.C.H., L.A.B., A.M., H.L.W., T.C.) and Center for Neurological Diseases (P.K., H.L.W., T.C.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (L.A.B.), Boston Children's Hospital; and Partners Pediatric Multiple Sclerosis Center (L.A.B., T.C.), Massachusetts General Hospital, Boston
| | - Pia Kivisakk
- From the Partners Multiple Sclerosis Center (M.T.M., B.C.H., L.A.B., A.M., H.L.W., T.C.) and Center for Neurological Diseases (P.K., H.L.W., T.C.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (L.A.B.), Boston Children's Hospital; and Partners Pediatric Multiple Sclerosis Center (L.A.B., T.C.), Massachusetts General Hospital, Boston
| | - Alexander Musallam
- From the Partners Multiple Sclerosis Center (M.T.M., B.C.H., L.A.B., A.M., H.L.W., T.C.) and Center for Neurological Diseases (P.K., H.L.W., T.C.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (L.A.B.), Boston Children's Hospital; and Partners Pediatric Multiple Sclerosis Center (L.A.B., T.C.), Massachusetts General Hospital, Boston
| | - Howard L Weiner
- From the Partners Multiple Sclerosis Center (M.T.M., B.C.H., L.A.B., A.M., H.L.W., T.C.) and Center for Neurological Diseases (P.K., H.L.W., T.C.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (L.A.B.), Boston Children's Hospital; and Partners Pediatric Multiple Sclerosis Center (L.A.B., T.C.), Massachusetts General Hospital, Boston
| | - Tanuja Chitnis
- From the Partners Multiple Sclerosis Center (M.T.M., B.C.H., L.A.B., A.M., H.L.W., T.C.) and Center for Neurological Diseases (P.K., H.L.W., T.C.), Brigham and Women's Hospital, Harvard Medical School, Boston; Department of Neurology (L.A.B.), Boston Children's Hospital; and Partners Pediatric Multiple Sclerosis Center (L.A.B., T.C.), Massachusetts General Hospital, Boston.
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25
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Benson LA, Maski KP, Kothare SV, Bourgeois BF. New onset epilepsy in Prader-Willi syndrome: semiology and literature review. Pediatr Neurol 2010; 43:297-9. [PMID: 20837313 DOI: 10.1016/j.pediatrneurol.2010.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Revised: 01/28/2010] [Accepted: 05/05/2010] [Indexed: 11/17/2022]
Abstract
Prader-Willi syndrome is a chromosomal disorder caused by absence of expression of the paternal active genes in the 15q11∼q13 chromosome region; it is associated with an increased incidence of epilepsy and narcolepsy. Presented here is the case of a 2.5-year-old boy with Prader-Willi syndrome and a history of neonatal superior sagittal sinus thrombosis with new onset of atonic seizures with electrographic onset from the parasagittal region. It is postulated that microscarring from neonatal venous sinus thrombosis, history of febrile seizures, and Prader-Willi syndrome are factors predisposing him to epilepsy. The importance of video electroencephalography with electromyography electrodes is emphasized for Prader-Willi syndrome patients with drop episodes, to differentiate cataplexy from seizures. This being a novel report of a Prader-Willi syndrome patient with atonic seizures, the literature on seizure semiology among patients with Prader-Willi syndrome is reviewed.
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Affiliation(s)
- Leslie A Benson
- Department of Neurology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02115, USA.
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26
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Benson LA, Barrett SF, Wright CHG. Characterization of selected elementary motion detector cells to image primitives. Biomed Sci Instrum 2008; 44:410-416. [PMID: 19141950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Developing a visual sensing system, complete with motion processing hardware and software would have many applications to current technology. It could be mounted on many autonomous vehicles to provide information about the navigational environment, as well as obstacle avoidance features. Incorporating the motion processing capabilities into the sensor requires a new approach to the algorithm implementation. This research, and that of many others, have turned to nature for inspiration. Elementary motion detector (EMD) cells are involved in a biological preprocessing network to provide information to the motion processing lobes of the house degrees y Musca domestica. This paper describes the response of the photoreceptor inputs to the EMDs. The inputs to the EMD components are tested as they are stimulated with varying image primitives. This is the first of many steps in characterizing the EMD response to image primitives.
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27
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George SK, Xu YH, Benson LA, Pratsch L, Peters R, Ihler GM. Cytochrome b5 and a recombinant protein containing the cytochrome b5 hydrophobic domain spontaneously associate with the plasma membranes of cells. Biochim Biophys Acta 1991; 1066:131-43. [PMID: 1906748 DOI: 10.1016/0005-2736(91)90179-c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Both cytochrome b5, isolated from rabbit liver microsomes, and LacZ:HP, a recombinant protein consisting of enzymatically active Escherichia coli beta-galactosidase coupled to the C-terminal membrane-anchoring hydrophobic domain of cytochrome b5, were shown to spontaneously associate with the plasma membranes of erythrocytes and 3T3 cells. Association was promoted by low pH values, but proceeded satisfactorily over several hours at physiological pH and temperature. About 150,000 cytochrome b5 molecules or 100,000 LacZ:HP molecules could be associated per erythrocyte. These proteins were not removed from the membrane by extensive washing, even at high ionic strength. After incubation with fluorescently labeled cytochrome b5 or LacZ:HP, cells displayed fluorescent membranes. The lateral mobility of fluorescently labeled cytochrome b5 and LacZ:HP was measured by photo-bleaching techniques. In the plasma membrane of erythrocytes and 3T3 cells, the apparent lateral diffusion coefficient D ranged from 1.0.10(-9) to 8.10(-9) cm2 s-1 with a mobile fraction M between 0.4 and 0.6. The lateral mobility of these proteins closely resembled that reported for lipid-anchored proteins and was much higher than that reported for Band 3, an erythrocyte membrane-spanning protein with a large cytoplasmic domain. These results suggest that the hydrophobic domain of cytochrome b5 could be employed as a universal, laterally mobile membrane anchor to associate a variety of diagnostically and therapeutically useful recombinant proteins with cells.
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Affiliation(s)
- S K George
- Department of Medical Biochemistry and Genetics, Texas A&M College of Medicine, College Station
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28
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Stover CK, de la Cruz VF, Fuerst TR, Burlein JE, Benson LA, Bennett LT, Bansal GP, Young JF, Lee MH, Hatfull GF. New use of BCG for recombinant vaccines. Nature 1991; 351:456-60. [PMID: 1904554 DOI: 10.1038/351456a0] [Citation(s) in RCA: 1203] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BCG, a live attenuated tubercle bacillus, is the most widely used vaccine in the world and is also a useful vaccine vehicle for delivering protective antigens of multiple pathogens. Extrachromosomal and integrative expression vectors carrying the regulatory sequences for major BCG heat-shock proteins have been developed to allow expression of foreign antigens in BCG. These recombinant BCG strains can elicit long-lasting humoral and cellular immune responses to foreign antigens in mice.
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MESH Headings
- Animals
- Antigens/genetics
- Antigens/immunology
- Antigens, Bacterial/genetics
- Antigens, Bacterial/immunology
- Antigens, Viral/genetics
- Antigens, Viral/immunology
- BCG Vaccine/genetics
- BCG Vaccine/immunology
- Base Sequence
- Cloning, Molecular
- Escherichia coli/genetics
- Gene Expression
- Genes, Bacterial
- Genetic Vectors
- HIV Antigens/genetics
- HIV-1/immunology
- Heat-Shock Proteins/genetics
- Mice
- Mice, Inbred BALB C
- Molecular Sequence Data
- Mycobacterium bovis/genetics
- Regulatory Sequences, Nucleic Acid
- Vaccines, Synthetic/genetics
- Vaccines, Synthetic/immunology
- beta-Galactosidase/genetics
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Affiliation(s)
- C K Stover
- MedImmune Incorporated, Gaithersburg, Maryland 20878
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29
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Abstract
Bartonella bacilliformis, which causes the human diseases Oroya fever and verruga peruana, binds to human erythrocytes in vitro and produces substantial and long-lasting deformations in erythrocyte membranes, including cone-shaped depressions, trenches, and deep invaginations. The deforming force is probably provided by the polar flagella of these highly motile bacteria. Deep invaginations containing bacteria are commonly seen, and membrane fusion at the necks of the invaginations leads to the formation of intracellular vacuoles containing bacteria. Fluorescent compounds present externally render the vacuoles fluorescent and, occasionally, lightly fluorescent cells are seen, suggesting that the vacuoles sometimes rupture to admit the bacteria to the cytoplasm. Vacuoles present in fluorescent erythrocytes prepared by preloading the erythrocytes with fluorescent compounds are seen as dark areas from which the fluorescent marker is excluded. Entry of the bacteria appears to be the result of a process of forced endocytosis.
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30
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Abstract
Lipid is necessary for calcification of a calculus matrix. Matrix was prepared by decalcification of dental calculus. The matrix calcified when it was exposed to a metastable calcium phosphate solution. After extraction with chloroform-methanol, the matrix lost the capacity to calcify. The lipid extract was calcifiable.
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