MOG antibody-associated optic neuritis in the setting of acute CMV infection

MOGAD optic neuritis after mild head/orbital trauma in six children

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a potential cause of optic neuritis (ON). Its triggers and etiologies are not completely understood. We describe a novel clinical observation in six young patients with MOGAD-ON in the setting of strikingly parallel histories of mild head/orbital trauma. This is a single-center retrospective case series of six young patients and age-matched isolated MOGAD-ON controls. We present data both individually (de-identified, only the six trauma-associated cases) and in aggregate. Averages are presented as the arithmetic mean +/- SEM. 6/27 patients with MOGAD-ON, (3/6 female), between 8 and 18 years old presented with ON 5.5 days after mild head trauma. Four patients developed ON ipsilateral to their unilateral head trauma while two developed bilateral ON following midline head trauma. All patients tested positive for serum anti-MOG antibodies upon ON workup. They all received intravenous corticosteroids with rapid improvement in symptoms (5.5 weeks to full visual recovery) and none have since relapsed. No other patients with MOGAD-ON experienced preceding head trauma, and all patients in the control group were asked about trauma upon assessment of the history. Head trauma may serve as an inciting event in the presentation and diagnosis of MOGAD-ON. This novel observation provides a potential pathophysiologic mechanism independent of infectious triggers, although we cannot determine if these patients were already predisposed towards MOGAD-ON.

MOG antibody-associated optic neuritis

Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) is a demyelinating disorder, distinct from multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). MOGAD most frequently presents with optic neuritis (MOG-ON), often with characteristic clinical and radiological features. Bilateral involvement, disc swelling clinically and radiologically, and longitudinally extensive optic nerve hyperintensity with associated optic perineuritis on MRI are key characteristics that can help distinguish MOG-ON from optic neuritis due to other aetiologies. The detection of serum MOG immunoglobulin G utilising a live cell-based assay in a patient with a compatible clinical phenotype is highly specific for the diagnosis of MOGAD. This review will highlight the key clinical and radiological features which expedite diagnosis, as well as ancillary investigations such as visual fields, visual evoked potentials and cerebrospinal fluid analysis, which may be less discriminatory. Optical coherence tomography can identify optic nerve swelling acutely, and atrophy chronically, and may transpire to have utility as a diagnostic and prognostic biomarker. MOG-ON appears to be largely responsive to corticosteroids, which are often the mainstay of acute management. However, relapses are common in patients in whom follow-up is prolonged, often in the context of early or rapid corticosteroid tapering. Establishing optimal acute therapy, the role of maintenance steroid-sparing immunotherapy for long-term relapse prevention, and identifying predictors of relapsing disease remain key research priorities in MOG-ON.

Uveitis and optic perineuritis in the context of myelin oligodendrocyte glycoprotein antibody seropositivity

BACKGROUND AND PURPOSE

Antibodies to myelin oligodendrocyte glycoprotein (MOG) have been identified in both children and adults with demyelination, with a strong association with bilateral or recurrent optic neuritis (ON). However, the full clinical spectrum of this newly described condition is unknown. We sought to describe non-ON inflammatory ophthalmological presentations such as uveitis and optic perineuritis in the context of MOG antibody seropositivity.

METHODS

Using a live cell-based assay analysed by flow cytometry, we identified seropositive patients referred for MOG antibody testing in Australasia between 2014 and 2017. We identified four MOG antibody-positive patients with non-ON inflammatory ophthalmological presentations and present their detailed clinical information in this case series.

RESULTS

Three patients had uveitis either in association with, or remote from, ON. One patient had optic perineuritis and peripheral ulcerative keratitis. We describe the presentation, examination, investigation findings and clinical course of these four patients.

CONCLUSIONS

Recognition of these novel clinical associations may expand the clinical spectrum of MOG antibody-associated presentations. An expedited diagnosis may guide the management of these complex patients.