Double hit - A case in point for dual seropositivity to AQP4 and MOG antibodies

AQP4-IgG NMOSD (anti-aquaporin-4 neuromyelitis optica spectrum disorder) and MOGAD (myelin oligodendrocyte glycoprotein antibody associated disease) are unique disorders among themselves, with rare reports of dual seropositivity being described. Evaluation with cell-based assays reduces the incidence of false positivity. The clinical features of these cases may either have a dominant phenotype or may evolve into one subsequently. We describe a young girl aged 18-year-old who presented with longitudinally extensive transverse myelitis and dual seropositivity to both AQP4 and MOG antibodies.

Cryptococcal infection causing longitudinal extensive transverse myelitis in an immunocompetent individual: Case report and literature review

Cryptococcal CNS infections in immunocompetent individuals are occasionally reported in literature. The spinal manifestations of cryptococcal CNS infections are epidural abscess, chronic arachnoiditis, intramedullary granuloma, myelitis and vasculitis. We report a rare case of CNS cryptococcal infection presenting as a longitudinal extensive transverse myelitis (LETM) in an immunocompetent male. This report highlights cryptococcus as an important etiology among infectious causes in acute LETM patients in-spite of the immunocompetent status of the patient and the utility of CRAG (cryptococcal antigen) for diagnosis in such patients. We also present a literature review of all reported cases of cryptococcal myelitis.

Acute Transverse Myelitis Following COVID-19 Vaccination

An increasing number of people are undergoing vaccination for COVID-19 because of the ongoing pandemic. The newly developed, genetically engineered mRNA vaccines are critical for controlling the epidemic disease. However, major adverse effects, including neuroimmunological disorders, are being attributed to this vaccine. For instance, several cases of acute transverse myelitis (ATM) after COVID-19 vaccination have been reported in clinical trials. Here, we report an exceedingly rare case of longitudinally extensive transverse myelitis (LETM), a rare subtype of ATM involving three or more vertebral segments, that occurred shortly after vaccination with the Moderna COVID-19 (mRNA-1273) vaccine, with a comorbidity of vitamin B12 deficiency. The findings of subsequent investigations suggest the possibility that autoimmune responses are triggered by the reactions between anti-SARS-CoV-2 spike protein antibodies and tissue proteins, as well as the interaction between spike proteins and angiotensin-converting enzyme 2 receptors.

Longitudinally extensive transverse myelitis following acute COVID-19 infection

Corona Virus Disease 2019 (COVID-19) is a new illness caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). With the increasing number of confirmed cases and the accumulating clinical data, a broad spectrum of neurological complications has been reported in the literature, including encephalopathy, stroke, Guillain-Barré syndrome, meningo-encephalitis, acute necrotizing hemorrhagic encephalopathy, and inflammatory central nervous system syndromes. Here, we describe the case of a 38-year-old woman presenting with longitudinally extensive transverse myelitis, revealed by bilateral lower limb weakness, decreased sensation below the Th4 level and urinary retention, and occuring 15 days after she had been diagnosed with COVID-19.

Etiological spectrum, clinico-radiological profile and treatment outcomes of longitudinally extensive transverse myelitis - A prospective study from Northwest India

OBJECTIVES

To study etiological, clinical and radiological profile and treatment outcomes in patients of longitudinally extensive transverse myelitis (LETM).

METHODS

This was a prospective study conducted at Dr. S.N. medical college, Jodhpur, India, of patients presenting with LETM between March 2018 to March 2020.

RESULTS

Our study included 32 patients (median age 32 years, female to male ratio of 2.5: 1). Neuromyelitis optica spectrum disorders (NMOsd) was the most common diagnosis affecting 14 patients followed by 5 patients of idiopathic myelitis, 4 patients of para-infectious myelitis, 3 patients of multiple sclerosis (MS), 3 patients of acute demyelinating encephalomyelitis (ADEM) and 1 patient each of myelin oligodendrocyte glycoprotein (MOG) antibody disease, sarcoidosis and mixed connective tissue disorder (MCTD). All the patients of NMOsd were positive for aquaporin 4 (AQP4) antibody. Spinal MRI showed central pattern of involvement in NMOsd and eccentric pattern of involvement in MS. All the patients of para-infectious myelitis were varicella myelitis. Twenty-eight (87.5%) patients had good clinical recovery at 6 months.

CONCLUSION

Although, LETM is classically associated with NMOsd, it can have multiple etiologies. Identifying the etiology is important for long term treatment and prognosis which varies according to the disease. Patients in our study presented with relapses and severe disease but had good clinical recovery with treatment.

Sequence Features of Mitochondrial Transporter Protein Families

Mitochondrial carriers facilitate the transfer of small molecules across the inner mitochondrial membrane (IMM) to support mitochondrial function and core cellular processes. In addition to the classical SLC25 (solute carrier family 25) mitochondrial carriers, the past decade has led to the discovery of additional protein families with numerous members that exhibit IMM localization and transporter-like properties. These include mitochondrial pyruvate carriers, sideroflexins, and mitochondrial cation/H+ exchangers. These transport proteins were linked to vital physiological functions and disease. Their structures and transport mechanisms are, however, still largely unknown and understudied. Protein sequence analysis per se can often pinpoint hotspots that are of functional or structural importance. In this review, we summarize current knowledge about the sequence features of mitochondrial transporters with a special focus on the newly included SLC54, SLC55 and SLC56 families of the SLC solute carrier superfamily. Taking a step further, we combine sequence conservation analysis with transmembrane segment and secondary structure prediction methods to extract residue positions and sequence motifs that likely play a role in substrate binding, binding site gating or structural stability. We hope that our review will help guide future experimental efforts by the scientific community to unravel the transport mechanisms and structures of these novel mitochondrial carriers.

An Unusual Association: Takayasu's Arteritis and Tubulointerstitial Nephritis and Uveitis Syndrome

The coexistence of two immune-mediated diseases in the same patient is unusual. Takayasu's arteritis (TA), which is a chronic granulomatous vasculitis, was discovered in a 47-year-old woman followed for tubulointerstitial nephritis and uveitis syndrome (TINU syndrome). We present the first case of this association.

LEARNING POINTS

Rare autoimmune diseases can coexist in the same patient.Physical examination is important so that coexisting diseases can be identified.Takayasu's arteritis was discovered as an incidental finding in a patient followed fortubulointerstitial nephritis and uveitis syndrome.

Myelin oligodendrocyte glycoprotein-antibody-associated disorder: a new inflammatory CNS demyelinating disorder

BACKGROUND AND AIMS

Myelin oligodendrocyte glycoprotein (MOG) is an oligodendrocytopathy resulting in demyelination. We aimed to determine the frequency of MOG-associated disorders (MOGAD), its various clinical phenotypes, and imaging characteristics.

METHODS

All patients with MOGAD were included. Description of the various clinical phenotypes, investigation profile, therapeutic response, differences between pediatric and adult-onset neurological disorders, determination of poor prognostic factors was done.

RESULTS

The study population consisted of 93 (M:F = 45:48) (Pediatric:40, Adult-onset:47, Late-onset:7) patients with a median age of 21 years. Among the 263 demyelinating episodes; 45.8% were optic neuritis (ON), 22.8% were myelopathy, 17.1% were brainstem, 7.6% were acute demyelinating encephalomyelitis(ADEM), 4.2% were opticomyelopathy and 2.3% with cerebral manifestations. There was exclusive vomiting in 24.7% prior to onset of clinical syndrome, none of them had area postrema involvement. ADEM was exclusively seen in pediatric patients. Poor prognostic indicators included: (i) incomplete recovery from an acute attack, (b) brainstem syndrome, (c) ADEM with incomplete recovery, (d) MRI suggestive of leukodystrophy pattern, (e) severe ON, (f) ADEMON.

CONCLUSIONS

The Spectrum of MOG-associated disorders is wider affecting the brain (grey and white matter) and the meninges. There are various clinical phenotypes and MRI patterns, recognition of which may help in the determination of therapeutic strategies, and long-term prognosis.

Life threatening rare lymphomas presenting as longitudinally extensive transverse myelitis: a diagnostic challenge

Background and aims - Description of two cases of rare intravascular large B-cell lymphoma and secondary T-cell lymphoma diagnosed postmortem, that manifested clinically as longitudinally extensive transverse myelitis (LETM). We discuss causes of diagnostic difficulties, deceptive radiological and histological investigations, and outline diagnostic procedures based on our and previously reported cases. Case reports - Our first case, a 48-year-old female was admitted to the neurological department due to paraparesis. MRI suggested LETM, but the treatments were ineffective. She died after four weeks because of pneumonia and untreatable polyserositis. Pathological examination revealed intravascular large B-cell lymphoma (IVL). Our second case, a 61-year-old man presented with headache and paraparesis. MRI showed small bitemporal lesions and lesions suggesting LETM. Diagnostic investigations were unsuccessful, including tests for possible lymphoma (CSF flow cytometry and muscle biopsy for suspected IVL). Chest CT showed focal inflammation in a small area of the lung, and adrenal adenoma. Brain biopsy sample from the affected temporal area suggested T-cell mediated lymphocytic (paraneoplastic or viral) meningoencephalitis and excluded diffuse large B-cell lymphoma. The symptoms worsened, and the patient died in the sixth week of disease. The pathological examination of the presumed adenoma in the adrenal gland, the pancreatic tail and the lung lesions revealed peripheral T-cell lymphoma, as did the brain and spinal cord lesions. Even at histological examination, the T-cell lymphoma had the misleading appearance of inflammatory condition as did the MRI. Conclusion - Lymphoma can manifest as LETM. In cases of etiologically unclear atypical LETM in patients older than 40 years, a random skin biopsy (with subcutaneous adipose tissue) from the thigh and from the abdomen is strongly recommended as soon as possible. This may detect IVL and provide the possibility of prompt chemotherapy. In case of suspicion of lymphoma, parallel examination of the CSF by flow cytometry is also recommended. If skin biopsy is negative but lymphoma suspicion remains high, biopsy from other sites (bone marrow, lymph nodes or adrenal gland lesion) or from a simultaneously existing cerebral lesion is suggested, to exclude or prove diffuse large B-cell lymphoma, IVL, or a rare T-cell lymphoma.

Neuromyelitis optica spectrum disorder and systemic lupus erythematosus

Neuromyelitis optica spectrum disorder is an inflammatory syndrome that is associated with many autoimmune conditions. We present the case of a patient who had longitudinally extensive transverse myelitis and antibodies to aquaporin 4 IgG (AQP4-IgG). Based on presence of lymphopenia, further workup revealed strong ANA positivity, anti-Sm antibodies, and low serum complements suggesting presence of systemic lupus erythematosus. The patient promptly responded to intravenous pulse methylprednisolone and five sessions of plasma exchange. At 1 year, she is on maintenance treatment with low dose prednisolone, azathioprine, and hydroxychloroquine, she has had no relapse and no other clinical features of lupus. This case is an illustration that neuromyelitis optica spectrum disorder can be the first manifestation of systemic lupus erythematosus.

Neuromyelitis optica spectrum disorder and systemic lupus erythematosus

Neuromyelitis optica spectrum disorder is an inflammatory syndrome that is associated with many autoimmune conditions. We present the case of a patient who had longitudinally extensive transverse myelitis and antibodies to aquaporin 4 IgG (AQP4-IgG). Based on presence of lymphopenia, further workup revealed strong ANA positivity, anti-Sm antibodies, and low serum complements suggesting presence of systemic lupus erythematosus. The patient promptly responded to intravenous pulse methylprednisolone and five sessions of plasma exchange. At 1 year, she is on maintenance treatment with low dose prednisolone, azathioprine, and hydroxychloroquine, she has had no relapse and no other clinical features of lupus. This case is an illustration that neuromyelitis optica spectrum disorder can be the first manifestation of systemic lupus erythematosus.

Non-Hodgkin Lymphoma With Longitudinally Extensive Transverse Myelopathy as the Initial Symptom: A Case Report

Identifying lymphoma as the cause of neurological disease is diagnostically challenging when the clinical manifestations are atypical. We report an unusual case of a previously healthy immunocompetent 67-years-old man presenting with acute onset of symptoms of myelopathy and mild personality changes. Magnetic resonance imaging (MRI) revealed multifocal periventricular lesions and longitudinally extensive transverse myelitis (LETM). He had very good response to corticosteroids and was in remission for over 6 months. Repeat MRI showed an unexpected mass lesion in the brain which was later confirmed by brain biopsy as diffuse large B cell lymphoma. Subsequent FDG-PET/CT revealed systemic disease with lymphonodal and testicular manifestations (Stage IV disease). It is therefore important to consider lymphoma as a differential diagnosis in patients with LETM and demyelinating lesions in the brain.

Intrathecal formation of anticardiolipin antibodies in a patient with SLE-related relapsing longitudinal myelitis: a possible pathogenic connection

BACKGROUND

Nontraumatic acute transverse myelitis (ATM) can occur in response to infectious, inflammatory and vascular triggers; 1% of patients with systemic lupus erythematosus (SLE) develop ATM, but the mechanism remains unknown.

OBJECTIVE

The objective of this case report is to describe a case of intrathecal formation of anticardiolipin antibodies (aCL) during SLE-related ATM.

METHODS

A single patient analysis was conducted.

RESULTS

A 26-year-old housewife was diagnosed with SLE at age 19. Circulating aCL antibodies were positive at diagnosis. At age 21, she developed an episode of severe sepsis. At 23 years of age she developed an episode of ATM that left her paraplegic with a D10 sensory level, from which she recovered partially. Three years later, she developed a clinical relapse of ATM. During that second episode, serum levels of aCL were within normal limits, while cerebrospinal fluid levels were increased, suggesting intrathecal production of aCL.

CONCLUSION

Here, we present a case of a woman who developed relapsing SLE-related longitudinally extensive ATM in whom intrathecal formation of aCL was demonstrated, suggesting that local production and cross-recognition of nervous tissue by those autoantibodies may be myelopathic.

Resolution of inflammation in neuromyelitis optica spectrum disorders

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSD) are a spectrum of neuroinflammatory disorders associated with autoimmune antibodies against aquaporin-4 (AQP4). Accumulating evidence suggests that inflammation is involved in NMOSD pathogenesis. Resolution of inflammation, which is a highly regulated process mediated by specialized pro-resolving lipid mediators (SPMs) is important to prevent over-responsive inflammation. Deficiency in resolution of inflammation may lead to or accelerates inflammatory diseases. However, whether resolution of inflammation is impaired in NMOSD is not known. The objective of this study was to analyze the levels of SPMs in the serum and cerebrospinal fluid (CSF) of NMOSD patients, and to explore the roles of SPMs in clinical features of NMOSD.

METHODS

Thirty-five patients with NMOSD, 34 patients with multiple sclerosis, and 36 patients with non-inflammatory neurological diseases were enrolled in this study. Pro-resolving mediators including Annexin A1 (ANXA1) and resolvin D1 (RvD1), as well as pro-inflammatory lipid mediator leukotriene B4 (LTB4) levels were analyzed by enzyme-linked immunosorbent assay. Pro- and anti-inflammatory cytokines as well as chemokine levels were analyzed using cytometric beads array (CBA).

RESULTS

Our results showed RvD1 levels were significantly decreased, whereas LTB4 levels were significantly increased in the CSF of NMOSD patients. AQP4-IgG titer was negatively correlated with RvD1 levels in the CSF of NMOSD patients.

CONCLUSIONS

Decreased RvD1 levels indicate impaired resolution of inflammation in NMOSD patients. AQP4-IgG may contribute to increased inflammation and lead to unresolved inflammation in NMOSD.

Optic neuritis with radiological longitudinal spinal cord involvement and seronegative anti-aquaporin antibody: Evidence from a case study

In recent years, not only the incidence of brain demyelinating disease has increased, but also it seems that the world is facing new forms of autoimmune diseases of the brain. Distinguishing these diseases from each other is very important, since each requires a different treatment. The new criteria that were put forward in 2015 were meant to pave the way for better diagnosis of these diseases called neuromyelitis optica spectrum disease (NMOSD). However, too much emphasis on the criteria based on the convergence and association of radiological findings with the clinical symptoms actually causes confusion in the diagnosis. Here, the case of a 16-year-old child suffering from optic neuritis has been discussed. Her cervical magnetic resonance imaging (MRI) revealed longitudinal extensive transverse myelitis (LETM); however, the patient had no symptoms of the spinal cord's involvement. According to the 2015 criterion, the diagnosis of NMOSD cannot be accepted for this patient. Therefore, this case report emphasizes on the modification of the existing criterion.

LETM presented with causalgia and ensued by sudden death

BACKGROUND

Longitudinally Extensive Transverse Myelitis LETM is a specific pattern of myelitis wherein at least three continuous vertebral segments are involved. Characteristically, it is a defining feature of neuromyelitis optica NMO. However, it is described in many other etiologies.

CASE PRESENTATION

We present a case of 60 year old male who presented with symptoms and signs of regional sympathetic dystrophy RSD followed by symptoms of myelitis. Spinal cord MRI revealed cervical LETM extending to the brainstem. In spite of serological negativity, treatment of suspected neuromyelitis optica spectrum disorder NMOSD was initiated and resulted in symptom relief. Meanwhile, sudden death occurred and autonomic dysreflexia was the main culprit.

CONCLUSIONS

This case suggests that RSD could be the mere primary presentation of LETM, discusses the differential diagnoses of LETM in elderly patients, and suggests the possible risk of autonomic dysreflexia in such patients.

Longitudinally extensive transverse myelitis suspected for isolated Neuro-Behçet: A diagnostic conundrum

Behçet disease (BD) is a chronic relapsing autoimmune disease. Involvement of the nervous system occurs in 5-50% and is referred to as Neuro-Behçet's (NBD). The clinical diagnosis of NBD can be challenging, particularly when the history is atypical and the systemic manifestations of the disorder are absent or scant. We report a young Caucasian man who presented with a non-specific systemic illness evolving rapidly to a basilar meningitis with a neutrophilic pleocytosis. Shortly afterwards, he developed a cervical myelopathy and ultimately a longitudinally extensive transverse myelitis and brainstem involvement with an active uveitis. There was no history of recurrent oral aphthous ulcers or genital ulcers, other skin lesions, or thrombophlebitis. The diagnosis was supported by the clinical, radiographic and laboratory findings including heterozygosity for the HLA-B51 allele on genetic testing. NBD must be included in the differential diagnosis of longitudinally extensive transverse myelitis, especially when it is associated with uveitis.