Relapses after SARS-CoV-2 vaccination in patients with neuromyelitis optica spectrum disorder and multiple sclerosis

BACKGROUND

The COVID-19 pandemic outbreak raises the question of whether immunization is recommended for patients with CNS demyelinating diseases. On the one hand, existing studies suggested that SARS-CoV-2 vaccinations are not associated with increased risk of relapse activity. On the other hand, case reports with acute CNS demyelinating disease post vaccination were emerging and raising clinicians' attention.

METHODS

In this longitudinal observational study, we included 556 patients with neuromyelitis optica spectrum disorder (NMOSD) and 280 patients with relapsing-remitting multiple sclerosis (RRMS). Each vaccinated patient was matched to two unvaccinated patients according to age, gender, ARR and immunotherapy status, based on propensity score matching model (PSM). The primary outcome is the short- and medium-term risk of relapse, which were evaluated by Kaplan-Meier analysis between groups.

RESULTS

In our cohort, 649 patients (77.6%) have not yet been vaccinated, mainly due to their concerns about relapse. After PSM, 109 vaccinated patients with NMOSD, 218 PS-matched unvaccinated patients with NMOSD, 78 vaccinated patients with RRMS, and 156 PS-matched unvaccinated patients with RRMS were included in the survival analysis to explore the safety of vaccines, with a median of 9-month follow-up. Following the first vaccination dose, 10 patients with NMOSD (9.2%) and four with RRMS (5.1%) experienced an acute relapse. Meanwhile, in the PS-matched unvaccinated group, 15 patients with NMOSD (6.9%) and 12 patients with RRMS (7.7%) presented with an acute relapse. There was no significant difference between the two curves in both NMOSD and RRMS groups over the course of the observation period. There were no significant differences in demographic characteristics, clinical characteristics, and symptoms of relapses between the vaccinated and PS-matched unvaccinated groups. Post vaccination adverse events (ADE) were reported in 39 individuals (20.9%).

CONCLUSION

Our results indicate that inactivated SARS-CoV-2 vaccines appear safe for patients with CNS demyelinating diseases.

Neuromyelitis optica spectrum disease coexisting with subacute combined degeneration: a case report

Background

Subacute combined degeneration (SCD) is a demyelinating disease characterized by vitamin B12 deficiency related segmental degeneration of the dorsal or lateral columns of the spinal cord. However, few cases have been reported as a comorbidity of SCD and neuromyelitis optica spectrum disease (NMOSD).

Case presentation

Herein, we describe a female patient (61-year-old) who had sensory deficits, paresthesia, and weakness of the distal extremities for over 2 months. She then received an initial diagnosis of SCD with typical inverted “V-sigh” hyperintensities over the posterior aspect of the spinal cord in magnetic resonance imaging (MRI - T2-weighted imaging), as well as megaloblastic anaemia in blood examinations. From the past history, there was no evidence of a dietary deficiency or gastric abnormalities. However, traditional treatment with vitamin B12 supplementation was ineffective. Hence, a demyelinating antibody examination showed that she had antibodies targeting aquaporin 4 (AQP4) in both the cerebrospinal fluid and serum, leading to the diagnosis of NMOSD. Her clinical symptoms were obviously improved after treatment with intravenous glucocorticoids.

Conclusion

People who have nutritional deficiency or altered gastrointestinal function are more likely to develop SCD. This case raises the awareness that the poor therapeutic effects of simple vitamin B12 supplementation could be explained by immunoreactions against AQP4. A better recognition will be of great importance for the correct diagnosis of the comorbidity, as well as for essential treatment and even a better prognosis.

MOG encephalomyelitis after vaccination against severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2): case report and comprehensive review of the literature

BACKGROUND

In around 20% of cases, myelin oligodendrocyte glycoprotein (MOG) immunoglobulin (IgG)-associated encephalomyelitis (MOG-EM; also termed MOG antibody-associated disease, MOGAD) first occurs in a postinfectious or postvaccinal setting.

OBJECTIVE

To report a case of MOG-EM with onset after vaccination with the Pfizer BioNTech COVID-19 mRNA vaccine BNT162b2 (Comirnaty®) and to provide a comprehensive review of the epidemiological, clinical, radiological, electrophysiological and laboratory features as well as treatment outcomes of all published patients with SARS-CoV-2 vaccination-associated new-onset MOG-EM.

METHODS

Case report and review of the literature.

RESULTS

In our patient, MOG-IgG-positive (serum 1:1000, mainly IgG1 and IgG2; CSF 1:2; MOG-specific antibody index < 4) unilateral optic neuritis (ON) occurred 10 days after booster vaccination with BNT162b2, which had been preceded by two immunizations with the vector-based Oxford AstraZeneca vaccine ChAdOx1-S/ChAdOx1-nCoV-19 (AZD1222). High-dose steroid treatment with oral tapering resulted in complete recovery. Overall, 20 cases of SARS-CoV2 vaccination-associated MOG-EM were analysed (median age at onset 43.5 years, range 28-68; female to male ratio = 1:1.2). All cases occurred in adults and almost all after immunization with ChAdOx1-S/ChAdOx1 nCoV-19 (median interval 13 days, range 7-32), mostly after the first dose. In 70% of patients, more than one CNS region (spinal cord, brainstem, supratentorial brain, optic nerve) was affected at onset, in contrast to a much lower rate in conventional MOG-EM in adults, in which isolated ON is predominant at onset and ADEM-like phenotypes are rare. The cerebrospinal fluid white cell count (WCC) exceeded 100 cells/μl in 5/14 (36%) patients with available data (median peak WCC 58 cells/μl in those with pleocytosis; range 6-720). Severe disease with tetraparesis, paraplegia, functional blindness, brainstem involvement and/or bladder/bowel dysfunction and a high lesion load was common, and treatment escalation with plasma exchange (N = 9) and/or prolonged IVMP therapy was required in 50% of cases. Complete or partial recovery was achieved in the majority of patients, but residual symptoms were significant in some. MOG-IgG remained detectable in 7/7 cases after 3 or 6 months.

CONCLUSIONS

MOG-EM with postvaccinal onset was mostly observed after vaccination with ChAdOx1-S/ChAdOx1 nCoV-19. Attack severity was often high at onset. Escalation of immunotherapy was frequently required. MOG-IgG persisted in the long term.

Impaired response of blood neutrophils to cell-death stimulus differentiates AQP4-IgG-seropositive NMOSD from MOGAD

BACKGROUND

In neuromyelitis optica spectrum disorders (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), neutrophils are found in CNS lesions. We previously demonstrated that NMOSD neutrophils show functional deficiencies. Thus, we hypothesized that neutrophil accumulation in the CNS may be facilitated by impairments affecting mechanisms of neutrophil death.

OBJECTIVE

To evaluate cell death in blood neutrophils from aquaporin-4 (AQP4)-IgG-seropositive NMOSD and MOGAD patients as well as matched healthy controls (HC) using in vitro assays.

METHODS

Twenty-eight AQP4 + NMOSD and 19 MOGAD patients in stable disease phase as well as 45 age- and sex-matched HC were prospectively recruited. To induce cell death, isolated neutrophils were cultured with/without phorbol 12-myristate 13-acetate (PMA). Spontaneous and PMA-induced NETosis and apoptosis were analyzed using 7-AAD and annexin-V by flow cytometry. Caspase-3 was assessed by western blot. Myeloperoxidase-DNA complexes (MPO-DNA), MPO and elastase were evaluated by ELISA, and cell-free DNA (cfDNA) by a fluorescence-based assay. Reactive oxygen species (ROS) were evaluated by a dihydrorhodamine 123-based cytometric assay. Serum GM-CSF, IL-6, IL-8, IL-15, TNF-ɑ and IL-10 were evaluated by multiplex assays, and neurofilament light chain (NfL) by single-molecule array assay.

RESULTS

In response to PMA, neutrophils from AQP4 + NMOSD but not from MOGAD patients showed an increased survival, and subsequent reduced cell death (29.6% annexin V⁺ 7-AAD⁺) when compared to HC (44.7%, p = 0.0006). However, AQP4 + NMOSD also showed a mild increase in annexin V⁺ 7-AAD^- early apoptotic neutrophils (24.5%) compared to HC (20.8%, p = 0.048). PMA-induced reduction of caspase-3 activation was more pronounced in HC (p = 0.020) than in AQP4 + NMOSD neutrophils (p = 0.052). No differences were observed in neutrophil-derived MPO-DNA or serum levels of MPO, elastase, IL-6, IL-8 and TNF-ɑ. IL-15 levels were increased in both groups of patients. In AQP4 + NMOSD, an increase in cfDNA, GM-CSF and IL-10 was found in serum. A positive correlation among cfDNA and NfL was found in AQP4 + NMOSD.

CONCLUSIONS

AQP4 + NMOSD neutrophils showed an increased survival capacity in response to PMA when compared to matched HC neutrophils. Although the data indicate that the apoptotic but not the NETotic response is altered in these neutrophils, additional evaluations are required to validate this observation.

Clinical features of organizing pneumonia in anti-aquaporin-4 antibody-positive neuromyelitis optica spectrum disorders

BACKGROUND

Anti-aquaporin-4 (AQP4) antibody is an autoantibody marker often observed in patients with neuromyelitis optica spectrum disorder (NMOSD). The pathological relevance of complicated pulmonary disorders in anti-AQP4 antibody-positive NMOSD remains unclear. We aimed to assess the clinical and histological relevance of complicated pulmonary disorders in anti-AQP4 antibody-positive NMOSD.

METHODS

We retrospectively reviewed the medical records of 52 patients with anti-AQP4 antibody-positive NMOSD and conducted immunohistochemical evaluations of the lung biopsy specimens.

RESULTS

Among 52 patients with anti-AQP4 antibody-positive NMOSD, 4 patients showed pulmonary involvement with a diagnosis of organizing pneumonia (OP). The proportion of males was larger (75% vs. 12.5%; p = 0.013) and creatine kinase levels were higher (458.3 U/L vs. 83.9 U/L; p = 0.003) in patients with OP than in those without OP. OP development preceded or coincided with the NMOSD symptoms. Chest computed tomography findings were consistent with OP in all four patients. Bronchoalveolar lavage fluid predominantly contained lymphocytes. Transbronchial lung biopsy revealed intraluminal plugs of inflammatory debris within the alveoli. Alveolar epithelial cells covering the OP lesions exhibited AQP4 loss, immunoglobulin G deposition, and complement activation. Corticosteroid treatment resulted in clinical improvement of OP.

CONCLUSION

OP may be considered a pulmonary manifestation of anti-AQP4 antibody-positive NMOSD beyond the central nervous system. Complement-dependent cytotoxicity of the lung epithelial cells caused by anti-AQP4 antibody is at least partly involved in OP development. When diagnosing NMOSD, the possibility of OP should be carefully evaluated based on the detailed history and chest imaging findings.

Time-varying connectivity of the precuneus and its association with cognition and depressive symptoms in neuromyelitis optica: A pilot MRI study

Background:

The precuneus is involved in cognition and depression; static functional connectivity (SFC) abnormalities of this region have been observed in neuromyelitis optica spectrum disorders (NMOSD). Time-varying functional connectivity (TVC) underpins dynamic variations of brain connectivity.

Objective:

The aim of this study was to explore precuneus SFC and TVC in NMOSD patients and their associations with neuropsychological features.

Methods:

This retrospective study includes 27 NMOSD patients and 30 matched healthy controls undergoing resting state functional magnetic resonance imaging (MRI) and a neuropsychological evaluation of cognitive performance and depressive symptoms. A sliding-window correlation analysis using bilateral precuneus as seed region assessed TVC, which was quantified by the standard deviation of connectivity across windows. Mean connectivity indicated SFC.

Results:

Compared to controls, patients had reduced SFC between precuneus, temporal lobe, putamen and cerebellum, and reduced TVC between precuneus and prefronto-parietal-temporo-occipital cortices and caudate. Patients also had increased intra-precuneal TVC and increased TVC between the precuneus and the temporal cortex. More severe depressive symptoms correlated with increased TVC between the precuneus and the temporal lobe; worse cognitive performance mainly correlated with higher TVC between the precuneus and the parietal lobe.

Conclusion:

TVC rather than SFC of the precuneus correlates with NMOSD neuropsychological features; different TVC abnormalities underlie depressive symptoms and cognitive impairment.

Comparison on the effect of seven drugs to prevent relapses of neuromyelitis optica spectrum disorders: A modeling analysis of literature aggregate data

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSD) is an immune-mediated demyelinating disease of the central nervous system. This study aimed to perform a comprehensive comparison of the effect of seven drugs to prevent relapses of NMOSD.

METHOD

A literature search was conducted using public databases. Clinical studies on the seven drugs (eculizumab, inebilizumab, satralizumab, rituximab, tocilizumab, azathioprine, and mycophenolate mofetil) to prevent relapses of NMOSD were identified. A time-course model was established using the time to first relapse as the primary endpoint, in order to evaluate the long-term effect of each drug in preventing relapse.

RESULTS

Twenty-four trials, including 2207 patients, were included in the model analysis. The results showed that monoclonal antibody therapy could significantly prolong the time to first relapse. Among all seven drugs, eculizumab can most significantly prevent patient from relapse. The estimated proportion of relapse-free patients treated with eculizumab was 98.9% at 24 months.

CONCLUSION

Based on the construction of a time-course pharmacodynamic model, this study made a comprehensive quantitative comparison of seven drugs for the treatment of NMOSD for the first time. These results can not only serve as a quantitative supplement for the rational use of drugs in clinical practice but also provide a pharmacodynamic reference for clinical trial design and decision making in the future.

Changes in the BTK/NF-κB signaling pathway and related cytokines in different stages of neuromyelitis optica spectrum disorders

Objective

Neuromyelitis optica spectrum disorders (NMOSDs) are blindness-causing neuritis; their pathogenesis is still not fully elucidated. Although it has been determined that Bruton tyrosine kinase (BTK) and NF-κB are associated with NMOSD, the changes that occur in different periods remain unknown. The study aimed to demonstrate the changes in the BTK/NF-κB pathway and related chemokines in different stages of NMOSDs.

Methods

A total of 32 patients with NMOSD were selected as the experimental group, and 32 healthy volunteers were included in the control group. In this study, the BTK/NF-κB pathway and related chemokines in the cerebrospinal fluid and peripheral blood samples of patients with NMOSD were analyzed in the acute or remission phase.

Results

BTK, NF-κB, PI3K, IKK, CXCL2, and CXCL12 levels in the NMOSD group in the acute or remission phase were significantly higher than those in the control group (p < 0.05).

Conclusion

The BTK/NF-κB pathway plays a vital role in the progression of NMOSD pathology. Our results shed light on its important role as a therapeutic target for NMOSD.

Experience with tocilizumab in patients with neuromyelitis optica spectrum disorders

INTRODUCTION

Neuromyelitis optica spectrum disorders (NMOSD) are immune-mediated inflammatory disorders of the central nervous system involving astrocytes, B lymphocytes, anti-aquaporin 4, and such inflammatory mediators as interleukin-6. Several immunosuppressants are used in their treatment. Tocilizumab, an interleukin-6 receptor antagonist, may be a treatment option.

METHOD

We performed an observational, retrospective study analysing parameters of effectiveness (annualised relapse rate, disability, and radiological progression) and safety of tocilizumab in patients with NMOSD in whom previous immunosuppressant treatment had failed. We aimed to evaluate the effectiveness and safety of tocilizumab in clinical practice in patients with NMOSD not responding to other immunosuppressants.

RESULTS

Five patients with NMOSD were analysed. Sixty percent of patients were women; mean age at diagnosis was 50±5.3 years and mean progression time was 4.5±3.6 years. Previously administered immunosuppressants were rituximab (in all 5), cyclophosphamide (2), and azathioprine (1). Mean time of exposure to tocilizumab was 2.3±1 years. Mean annualised relapse rate was 1.8±1.3 in the year prior to the introduction of tocilizumab and 0.2±0.4 the year after (P<.05), representing a reduction of 88.9%.

CONCLUSIONS

In our experience, tocilizumab is safe and effective in patients with NMOSD showing no response to other immunosuppressants.

Fractional anisotropy helps to differentiate the optic nerve impairment between neuromyelitis optica spectrum disorders and multiple sclerosis

OBJECTIVES

To assess the characteristics of optic nerve impairment between neuromyelitis optica spectrum disorders (NMOSD) and multiple sclerosis (MS) patients by fractional anisotropy (FA).

METHODS

Thirty-one NMOSD patients, 25 MS patients, and 17 heathy controls (HC) who underwent optic nerve DTI were included. The optic nerves of the NMOSD and MS patients were divided into vision-impaired (VI) subgroups and normal-appearing (NA) subgroups according to visual status, respectively. FA values were measured in the anterior, middle, and posterior segments of each intraorbital optic nerve.

RESULTS

FA values in VI NMOSD were significantly decreased in the whole optic nerve, especially the posterior segment of the optic nerve (p < 0.001). FA values measured in the anterior and middle segments of the optic nerve in VI MS were significantly decreased as compared to those in the HC (p < 0.05). Between NMOSD and MS, FA values in the posterior segment of the optic nerve showed significant differences (VI NMOSD vs. VI MS, 0.458 ± 0.097 vs. 0.568 ± 0.098, p < 0.001; NA NMOSD vs. NA MS, 0.568 ± 0.098 vs. 0.600 ± 0.085, p = 0.041, respectively). The signal intensity ratio (SIR) in the posterior segment of the optic nerve was significantly increased in VI NMOSD as compared with VI MS (p = 0.002). The combination of SIR and FA for distinguishing VI NMOSD from VI MS resulted in sensitivity, specificity, and positive and negative predictive values of 86.49%, 80.00%, 88.9%, and 76.2%, respectively.

CONCLUSION

FA could quantify the characteristics of NMOSD- and MS-related optic nerve impairment. DTI was a simple and effective imaging tool to differentiate between the two.

KEY POINTS

• NMOSD-related optic nerve impairment is extensive, often greater than half of the optic nerve, with the most significant involvement of the posterior segment of the optic nerve. • MS-related optic nerve impairment is more limited than NMOSD, and anterior and middle optic nerve involvement is common. • Optic nerve DTI is a convenient and effective imaging tool that can help characterize NMOSD and MS.

Anti-aquaporin-4 immunoglobulin G colorimetric detection by silver nanoparticles

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory and autoimmune disease whose biomarker is the anti-AQP4-IgG autoantibody that binds to aquaporin-4 (AQP4) protein. We introduced a nanosensor with a sensitivity of 84.6%, higher than the CBA's 76.5%. Using silver nanoparticles (AgNPs), we detected not only seropositive but also some false-negative patients previously classified with CBA. It consisted of AgNPs coated with one of a panel of 5 AQP4 epitopes. The ability in detecting the anti-AQP4-IgG in NMOSD patients depended on the epitope and synergy could be obtained by combining different epitopes. We demonstrated that NMOSD patients could easily be distinguished from healthy subjects and patients with multiple sclerosis. Using the most sensitive AQP4_61-70 peptide, we established a calibration curve to estimate the concentration of anti-AQP4-IgG in seropositive NMOSD patients. The ability to enhance the accuracy of the diagnosis may improve the prognosis of 10-27% of anti-AQP4-IgG seronegative patients worldwide.

Experience with tocilizumab in patients with neuromyelitis optica spectrum disorders

INTRODUCTION

Neuromyelitis optica spectrum disorders (NMOSD) are immune-mediated inflammatory disorders of the central nervous system involving astrocytes, B lymphocytes, anti-aquaporin 4, and such inflammatory mediators as interleukin-6. Several immunosuppressants are used in their treatment. Tocilizumab, an interleukin-6 receptor antagonist, may be a treatment option.

METHOD

We performed an observational, retrospective study analysing parameters of effectiveness (annualised relapse rate, disability, and radiological progression) and safety of tocilizumab in patients with NMOSD in whom previous immunosuppressant treatment had failed. We aimed to evaluate the effectiveness and safety of tocilizumab in clinical practice in patients with NMOSD not responding to other immunosuppressants.

RESULTS

Five patients with NMOSD were analysed. Sixty percent of patients were women; mean age at diagnosis was 50±5.3 years and mean progression time was 4.5±3.6 years. Previously administered immunosuppressants were rituximab (in all 5), cyclophosphamide (2), and azathioprine (1). Mean time of exposure to tocilizumab was 2.3±1 years. Mean annualised relapse rate was 1.8±1.3 in the year prior to the introduction of tocilizumab and 0.2±0.4 the year after (P <.05), representing a reduction of 88.9%.

CONCLUSIONS

In our experience, tocilizumab is safe and effective in patients with NMOSD showing no response to other immunosuppressants.

Therapeutic plasma exchange for optic neuritis attacks in patients with neuromyelitis optica spectrum disorders

BACKGROUND

Optic neuritis (ON) cause several sequela. Aggressive treatment with plasma exchange (TPE) is an option. This study describe improvement and safety outcomes with TPE.

METHODS

We recruited adults with ON in neuromyelitis optica spectrum disorders (NMOSD) patients treated with TPE. The primary outcome was an improvement in the visual acuity scale (VOS). We described the data and used multivariate logistic regression to identify factors associated with response.

RESULTS

83 patients received 558 TPE sessions. Mean age 40.9 years (±13.7 years); 73.5% women, 50.1% first attack, and 10.7% bilateral. Median VOS: 5 (range [R], 2-7). Median time between onset and TPE was 8 days (R, 1-32. By Keegan's criteria 82.4% experience improvement, 78.3% improve in at least 1 point in VOS. Age and pre-TPE VOS were related with improvement. Low fibrinogen occurs in 26% sessions.

CONCLUSION

TPE is effective and safety for ON. There is a need for a clinical trial using a therapeutic equivalent.

Emerging drugs for the acute treatment of relapses in adult neuromyelitis optica spectrum disorder patients

INTRODUCTION

Neuromyelitis optica spectrum disorders (NMOSD) are rare but often devastating neuroinflammatory autoimmune diseases of the central nervous system. Acute treatment is critically important and it should be initiated early and aggressively, as relapses result in severe residual disability. Acute treatments are still based on clinical experience and observational studies. The most commonly used treatments are steroids and plasmapheresis. Several new treatments to improve management and recovery after relapses in NMOSD are currently under investigation.

AREAS COVERED

: This review discusses current and the most recent advances in active development of phase II/III clinical trials for acute treatment options and therapeutic strategies that can help management improvement of NMOSD during a relapse. These treatments include bevacizumab, ublituximab and HBM9161.

EXPERT OPINION

NMOSD relapses require prompt evaluation and timely treatment to restore function and mitigate disability. Timing is critical. Plasmapheresis showed better outcomes in terms of recovery when compared to high-dose intravenous methylprednisolone alone. Some groups suggest that plasmapheresis could be considered as an initial treatment approach in different clinical scenarios due to its higher effectiveness. Future research and/or real-world data will establish the advantages and disadvantages of these new treatments and define the appropriate patient profile.

Clinical and prognostic aspects of patients with the Neuromyelitis Optica Spectrum Disorder (NMOSD) from a cohort in Northeast Brazil

Introduction

Neuromyelitis optica spectrum disorders (NMOSD) is a rare inflammatory and demyelinating disease of the central nervous system (CNS) more frequent in women and Afro-descendants. No previous epidemiological or prognostic study has been conducted in the region of the state of Bahia, Brazilian Northeast.

Objective

To evaluate clinical and prognostic aspects in patients with NMOSD from a cohort in northeastern Brazil.

Material and methods

A single-center retrospective study was conducted with consecutive patients diagnosed with NMOSD. Clinical and epidemiological characteristics were described. The degree of disability was expressed by the Expanded Disability Status Scale (EDSS). Worsening disability were analyzed through negative binomial regression adjusted for disease duration.

Results

Ninety-one patients were included, 72 (79.1%) female and 67 (73.6%) afro descendants. Mean age at onset was 36 (± 14) years and 73.3% were anti-aquaporin-4 antibody positive. Isolated transverse myelitis (32.9%) and isolated optic neuritis (22.4%) were the most frequent initial clinical syndromes. After multivariate analysis, optic neuritis (RR = 0.45; 95% CI = 0.23 – 0.88; p = 0.020) and dyslipidemia (RR = 0.40; 95% CI = 0.20 – 0.83; p = 0.014) were associated with slower disease progression. Area postrema involvement (RR = 6.70; 95% CI = 3.31 – 13.54; p < 0.001) and age at onset (RR = 1.03; 95% CI = 1.01 – 1.05; p = 0.003) were associated with faster disease progression.

Conclusions

In the first clinical and prognostic study in northeastern Brazil, we identified area postrema involvement, age at onset, optic neuritis at fist syndrome and dyslipidemia as the main prognostic factors associated with disease progression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02621-5.

• Isolated transverse myelitis was the most frequent initial clinical syndrome.

• Optic neuritis as first clinical syndrome was independently associated with better prognostic.

• Age at onset were associated with faster disease progression.

• Hashimoto's thyroiditis was the most frequent autoimmune disease in NMOSD.

Vaccination in neuromyelitis optica spectrum disorders: Friend or enemy?

Neuromyelitis optica spectrum disorders (NMOSDs) are uncommon antibody-mediated autoimmune diseases of the central nervous system (CNS), mainly occurring in optic nerves and spinal cord, which can cause visual impairment, paralysis, and occasionally bulbar dysfunction. Such neurological deficits can adversely affect pulmonary functions and increase complicated infection risk. Besides, most NMOSD patients undergo immunosuppressive therapy. All these factors make NMOSD patients the potential high-risk group under the current pandemic of coronavirus disease 2019 (COVID-19). Meanwhile, COVID-19 infection has already been demonstrated as a risk factor for NMOSD relapses. This review discusses the basic immunology of vaccination and common problems, including immunogenicity, safety, and efficacy of vaccination on NMOSD patients. Additionally, we offered vaccination recommendations, health care and treatment advice for NMOSD patients under the background of COVID-19.

The Turkish experience of COVID-19 infection in people with NMOSD and MOGAD: A milder course?

BACKGROUND

COVID-19 is a multisystemic infection with variables consequences depending on individual and comorbid conditions. The course and outcomes of COVID-19 during neuromyelitis optica spectrum disorders (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disorders (MOGAD) are not clearly known.

OBJECTIVE/METHODS

The aim of this study was to examine the features and outcomes of COVID-19 infection in NMOSD and MOGAD patients. The patients' demographic and clinical factors, disease modifying treatment (DMT) used and disease information of COVID-19 infection were recorded. Conditions leading to hospitalization and severe exposure to COVID-19 infection were also analyzed.

RESULTS

The study included 63 patients from 25 centers. Thirty-two patients (50.8%) belong to AQP-4 seropositive group, 13 (20.6%) and 18 (28.6%) were in MOG-positive and double-seronegative groups, respectively. Risk factors for severe COVID-19 infection and hospitalization were advanced age, high disability level and the presence of comorbid disease. Disease severity was found to be high in double-seronegative NMOSD and low in MOGAD patients. No statistically significant effect of DMTs on disease severity and hospitalization was found.

CONCLUSION

In NMOSD and MOGAD patients, advanced age, high disability and presence of comorbid disease pose risks for severe COVID-19 infection. There was no direct significant effect of DMTs for COVID-19 infection.

Auditory evoked potentials in children and adolescents with multiple sclerosis and neuromyelitis optica spectrum disorders

BACKGROUND

In children, an acute demyelinating disease may evolve as a multiphasic disease with multiple relapses, such as multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). The Brainstem Auditory Evoked Potentials (BAEP) and Long-Latency Auditory Evoked Potentials (LLAEP) contribute to the identification of either retrocochlear changes or other central auditory nervous system (CANS) changes.

OBJECTIVES

To characterize BAEP and LLAEP in children and adolescents with MS and NMOSD and verify the diagnostic values of these potentials in each of the demyelinating diseases.

METHODS

The 40 participants were divided into two study groups (SG1 - MS, SG2 - NMOSD) and two comparison groups (CG1 and CG2), matched for age (9 years-17 years and 11 months) and sex. Electrophysiological hearing assessment was performed with BAEP and LLAEP.

RESULTS

When SG1 and SG2 were compared with CG1 and CG2 regarding BAEP and LLAEP, both SG1 and SG2 presented a higher occurrence of changes. Also, individuals with MS had higher occurrences of BAEP changes, whereas individuals with NMOSD had a higher occurrence of LLAEP changes.

CONCLUSIONS

BAEP and LLAEP in children and adolescents with MS or NMOSD showed higher latencies and lower amplitudes of some components when these individuals were compared with their peers. These procedures were highly accurate to identify demyelinating diseases. BAEP results were more abnormal in individuals with MS, while LLAEP was so with NMOSD. These findings indicate that the auditory evoked potentials are important instruments for the differential diagnosis of MS and NMOSD, and valuable to monitor disease evolution.

Incidence and risk factors for venous thromboembolism during an acute attack in patients with neuromyelitis optica spectrum disorders

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSD) patients may be at increased risk of venous thromboembolism (VTE) during the acute attack, but evidence is limited.

OBJECTIVE

To investigate the incidence of venous thromboembolism (VTE) in Neuromyelitis optica spectrum disorders (NMOSD) patients with an acute attack and to identify the potential risk factors for the development of VTE.

METHODS

We conducted a retrospective study of NMOSD patients with an acute attack between January 1, 2015, and June 31, 2021. Diagnosis of DVT or PE was objectively confirmed by doppler ultrasound or computed tomographic pulmonary angiography (CTPA) during their acute hospital stay.

RESULTS

We identified 184 attacks in 128 NMOSD patients with the mean age of 46.9 years at the time of the attack and female predominance (152/184, 83.2%). VTE occurred in 22 (12.0%) attacks. Among the 22 attacks, 20 presented with transverse myelitis (TM), 1 cerebral syndrome (CS), and 1 simultaneous TM and brainstem syndrome (BS). Multivariable logistic regression analysis showed that advanced age [odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.04-1.12, p = 0.000], Nadir Expanded Disability Status Scale (EDSS)>6.5(OR = 3.39, 95% CI = 1.22-10.10, p = 0.029) and intravenous immunoglobulin (IVIG) treatment (OR = 3.21, 95% CI = 1.15-8.91, p = 0.025) were independent risk factors for the development of VTE in the total NMOSD cohort. In the subgroup analysis of the NMOSD patients with TM, age at attack (OR = 1.07, 95% CI = 1.03-1.11, p = 0.002) and IVIG treatment (OR = 4.23, 95% CI = 1.44-12.45, p = 0.009) were independent risk factors for the development of VTE in the total NMOSD cohort, but Nadir EDSS>6.5 was not an independent risk factor.

CONCLUSIONS

VTE is a frequent complication in NMOSD patients, especially in patients with TM. Advanced age and IVIG are independent risk factors for VTE. Immobilization is an independent risk factor for VTE in the total NMOSD cohort but not in the subgroup analysis of the patients with TM.

Visual Evoked Potentials in Neuromyelitis Optica Spectrum Disorders

Background

Neuromyelitis optica spectrum disorders (NMOSDs) are rare antibody-mediated disorders of the central nervous system, with a predilection for the spinal cord and optic nerves. The clinical utility of evoked potential recordings (EPs) has already been established for multiple sclerosis, in particular, that of the abnormal visual evoked potentials (VEP), a key criterion in the McDonald diagnostic criteria for MS. However, there have been few reports on EPs in patients with NMOSD.

AIM

The aim of our study was to assess the possible involvement of the optical pathway through VEP responses in patients with NMOSD.

Methods

VEPs were prospectively performed in 13 patients with NMOSD. All the patients were recruited from the outpatient clinic of a demyelinating diseases center. The recording was done as recommended by the International Federation of Clinical Neurophysiology.

Results

We evaluated the eyes of 12 women with a mean age of 42 years and of one man who was 25 years old. In 6 of the examined eye samples, a response was not obtained, while in the remaining 20 eye samples, we found a significant increase in P100 latency without amplitude change.

Conclusion

VEPs showed a significant increase in P100 latency. VEP assessment is a non-invasive, painless, fast, and low-cost exam that provides neurophysiological data for diagnosis of NMOSD.

Platelet-to-lymphocyte ratio differs between MS and NMOSD at disease onset and predict disability

BACKGROUND

We aimed to assess platelet-to-lymphocyte (PLR) and neutrophil-to-lymphocyte ratios (NLR) for differentiating multiple sclerosis (MS) from aquaporin-4-antibody-positive neuromyelitis optica spectrum disorders (NMOSD) at disease onset.

METHODS

We retrospectively enrolled and reviewed the medical records of patients with MS (N = 50) and NMOSD (N = 33) followed in specialized MS/NMOSD centers from Argentina. Demographical and clinical (manifestation and disability) data and neuroradiological features (new/enlarging or contrast-enhancing lesions) were assessed at baseline, 1 and 2 years. Serum samples were obtained during the first relapse without a previous acute or chronic treatment, at 1 and 2 years. Mixed-effects model was used to identify independent associations between the log-transformed NLR or PLR and MS/NMOSD outcomes.

RESULTS

PLR is increased in NMOSD when compared to MS (229.4 ± 86.74 vs. 186.6 ± 70.17, P = 0.01), but no significant differences were found for NLR (3.51 ± 1.29 vs. 3.30 ± 1.17, P = 0.43). PLR was the only independent predictor of poor physical disability score (EDSS ≥ 4) in NMOSD patients at 2 years (β=0.28, p = 0.02) after applying multivariate mixed-effects regression analysis. Additionally, multivariate logistic regression analysis showed that the PLR was the only independent predictor of EDSS ≥ 4 at 2 years (OR 28.8, p = 0.041) in the NMOSD group. The area under the receiver-operating characteristic curve was 0.841.

CONCLUSION

PLR could be potentially useful as additional diagnostic tool in differentiating these two neuroinflammatory conditions at presentation. PLR can predict severity of neurological disability at 2 years in NMOSD patients.

Lymphocyte Subsets Are Associated with Disease Status in Neuromyelitis Optica Spectrum Disorders

OBJECTIVE

At present, studies on lymphocytes are mostly conducted on CD19+ B cells and CD27+ B cells in neuromyelitis optica spectrum disorders (NMOSDs), but the exact changes in lymphocyte subsets (CD19+ B cells, CD3+ T cells, CD4+ Th cells, CD8+ Ts cells, the CD4+/CD8+ ratio, and NK [CD56+ CD16] cells) have rarely been studied. This study aimed to assess lymphocyte subset changes in patients with NMOSD.

METHODS

We performed a cross-sectional study of consecutive patients with acute NMOSD (n = 41), chronic NMOSD (n = 21), and healthy individuals (n = 44). Peripheral blood samples were obtained upon admission, and lymphocyte subsets were analyzed by flow cytometry. Levels of lymphocyte subsets among 3 groups were compared and its correlation with the length of spinal cord lesions was analyzed.

RESULTS

The levels of peripheral blood CD19+ B cells were significantly higher in patients with acute and chronic NMOSD than in healthy controls (HCs) (17.91 ± 8.7%, 13.08 ± 7.562%, and 12.48 ± 3.575%, respectively; p < 0.001) and were positively correlated with the length of spinal cord lesions in acute NMOSD (r = 0.433, p < 0.05). The peripheral blood CD4+/CD8+ ratio was significantly lower in patients with acute NMOSD and chronic NMOSD than in HCs (1.497 ± 0.6387, 1.33 ± 0.5574, and 1.753 ± 0.659, respectively; p < 0.05), and the levels of peripheral blood NK (CD56+ CD16) cells were significantly lower in patients with acute and chronic NMOSD than in HCs (13.6 ± 10.13, 11.11 ± 7.057, and 14.7 [interquartile range = 9.28], respectively; p < 0.01).

CONCLUSIONS

The levels of certain subsets of peripheral blood lymphocytes are associated with disease status in NMOSD.

Uncommon inflammatory/immune-related myelopathies

The differential diagnosis for immune-mediated myelopathies is broad. Although clinical manifestations overlap, certain presentations are suggestive of a particular myelopathy etiology. Spine MRI lesion characteristics including the length and location, and the pattern of gadolinium enhancement, help narrow the differential diagnosis and exclude an extrinsic compressive cause. The discovery of specific antibodies that serve as biomarkers of myelitis such as aquaporin-4-IgG and myelin-oligodendrocyte -glycoprotein-IgG (MOG-IgG), has improved our understanding of myelitis pathophysiology and facilitated diagnosis. In this review we will focus on the pathophysiology, clinical presentation, imaging findings and treatment and outcomes of uncommon immune-mediated myelopathies.

A comparative study of alteration in retinal layer segmentation alteration by SD-OCT in neuromyelitis optica spectrum disorders: A systematic review and meta-analysis

Background

To evaluate the feature of different retinal layer segmentation in neuromyelitis optica spectrum disorders (NMOSD) with spectral-domain optical coherence tomography (SD-OCT) and to compare it with that in multiple sclerosis (MS), healthy controls (HC), and idiopathic optic neuritis (ION).

Methods

We retrieved four electronic databases, including Pubmed, Embase, Cochrane Library, and Web of Science from inception to September 1st, 2021. A meta-analysis was performed to compare different retinal layer segmentation thicknesses between patients with or without a history of optic neuritis (ON) in NMOSD and the control group, including patients with MS, HC, and ION.

Results

Forty-two studies were included and the interval between the last ON onset and examination was greater than 3 months. Compared with that in HC eyes, the loss of retinal nerve fiber layer (RNFL) and macular ganglion cell and inner plexiform layer (GC-IPL) was serious in NMOSD eye especially after ON. Moreover, compared with that in ION eyes or MS-related-ON eyes, the injury to the peripapillary retinal nerve fiber layer (pRNFL) was severe in NMOSD-related-ON eyes. In addition, the correlation coefficient between pRNFL and prognostic visual acuity was 0.43. However, the one-arm study revealed the inner nuclear layer (INL) was thickened in NMOSD-related-ON eyes compared with HC eyes.

Conclusions

Inclusion of the RNFL and macular GC-IPL is recommended for monitoring disease progression and attention should be paid to changes in the INL.

Neuromyelitis optica spectrum disorders: A nationwide Portuguese clinical epidemiological study

INTRODUCTION

Neuromyelitis optica spectrum disorder (NMOSD) is a rare disorder in which astrocyte damage and/or demyelination often cause severe neurological deficits.

OBJECTIVE

To identify Portuguese patients with NMOSD and assess their epidemiological/clinical characteristics.

METHODS

This was a nationwide multicenter study. Twenty-four Portuguese adult and 3 neuropediatric centers following NMOSD patients were included.

RESULTS

A total of 180 patients met the 2015 Wingerchuk NMOSD criteria, 77 were AQP4-antibody positive (Abs+), 67 MOG-Abs+, and 36 seronegative. Point prevalence on December 31, 2018 was 1.71/100,000 for NMOSD, 0.71/100,000 for AQP4-Abs+, 0.65/100,000 for MOG-Abs+, and 0.35/100,000 for seronegative NMOSD. A total of 44 new NMOSD cases were identified during the two-year study period (11 AQP4-Abs+, 27 MOG-Abs+, and 6 seronegative). The annual incidence rate in that period was 0.21/100,000 person-years for NMOSD, 0.05/100,000 for AQP4-Abs+, 0.13/100,000 for MOG-Abs+, and 0.03/100,000 for seronegative NMOSD. AQP4-Abs+ predominated in females and was associated with autoimmune disorders. Frequently presented with myelitis. Area postrema syndrome was exclusive of this subtype, and associated with higher morbidity/mortality than other forms of NMOSD. MOG-Ab+ more often presented with optic neuritis, required less immunosuppression, and had better outcome.

CONCLUSION

Epidemiological/clinical NMOSD profiles in the Portuguese population are similar to other European countries.