Myelin oligodendrocyte glycoprotein antibodies in neurological disease

Electroacupuncture ameliorates cognitive impairment and white matter injury in vascular dementia rats via activating HIF-1α/VEGF/VEGFR2 pathway

Vascular dementia (VaD) significantly impairs patients' quality of life and imposes a major social and economic burden. Electroacupuncture (EA), a contemporary modification of traditional acupuncture, has demonstrated potential in improving cognitive function in VaD, particularly when applied at the Shenting and Baihui. However, the underlying mechanisms remain inadequately understood. Elucidating how EA ameliorates cognitive deficits is critical for validating its clinical application and advancing non-pharmacological interventions for neurodegenerative disorders. This study aimed to investigate the neuroprotective mechanisms of electroacupuncture at these acupoints on cognitive function in VaD rats. VaD was induced in male Sprague-Dawley rats through bilateral common carotid artery occlusion (BCAO), with sham rats serving as controls. Rats were subsequently divided into three groups: BCAO, BCAO + EA and BCAO + EA + YC-1 (a HIF-1α inhibitor). Electroacupuncture was applied to the Shenting and Baihui. Cerebral blood flow (CBF) was measured using dynamic susceptibility contrast functional MRI, and cognitive recovery was evaluated through the Morris water maze. Immunohistochemical analysis quantified myelin repair and angiogenesis, while expression of HIF-1α, VEGF and VEGFR2 in white matter was quantified using PCR and Western blot. The results indicated that electroacupuncture improved learning and memory, increased CBF, enhanced myelin recovery and promoted angiogenesis in VaD rats. The expression of HIF-1α, VEGF and VEGFR2 in the white matter was significantly elevated in VaD rats. Electroacupuncture at Shenting and Baihui activates the HIF-1α/VEGF/VEGFR2 pathway, enhances angiogenesis, white matter perfusion and myelin repair, thereby restoring cognitive function in VaD rats.

Clinical characteristics of late-onset neuromyelitis optica spectrum disorder in China

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSD) are central nervous system demyelinating diseases that are distinct from multiple sclerosis. According to epidemiological studies, the incidence of NMSOD peaks in individuals aged 30-40 years. Therefore, whether the clinical manifestations and prognoses of NMOSD differ on the basis of age at onset is worthy of further investigation.

METHODS

The clinical, laboratory, and imaging data of NMOSD patients admitted to Peking University Third Hospital were retrospectively analyzed. EO-NMOSD was defined early onset NMOSD (age at onset < 50 years), and LO-NMOSD was defined as late onset NMOSD (age at onset > 50 years). Differences in clinical and imaging data were compared between the two groups.

RESULTS

A total of 75 patients with NMOSD were enrolled. Among them, 45 patients were age <50 years (EO-NMOSD), and 30 patients were age ≥ 50 years (LO-NMOSD). There was no significant difference in the EDSS score between the two groups at the time of onset (p = 0.071). The median EDSS scores at the last follow-up were 2 points and 3.5 points in the EO-NMOSD and LO-NMOSD groups, respectively, and the difference was statistically significant (p = 0.001). The proportions of patients with EDSS scores ≤ 3 points and 3 < EDSS scores ≤ 6 points were significantly different between the two groups (p = 0.023, p = 0.014), and there was no significant difference in the proportion of patients with EDSS scores greater than 6 points between the two groups (p = 1.000). Spearman correlation analysis revealed that age at onset was positively correlated with EDSS scores at onset (r = 0.284, p = 0.013) and EDSS scores at the last follow-up (r = 0.425, p = 0.000) and negatively correlated with the number of attacks (r = -0.280, p = 0.015). The proportion of AQP4-ab(+) patients with EDSS scores < 3 at onset was lower in the LO-NMOSD group than in the EO-NMOSD group (27.2 % vs. 59.5 %, p = 0.017), and the proportion of AQP4-ab(+) patients with 3 < EDSS scores ≤ 6 was greater in the LO-NMOSD group than in the EO-NMOSD group, both at onset (72.7 % vs. 32.4 %, p = 0.003) and at the last follow-up (54.5 % vs. 24.3 %, p = 0.019). In addition, the proportion of patients with hypertension in the AQP4-ab(+) group of patients with LO-NMOSD was significantly greater than that in the AQP4-ab(+) group of patients with EO-NMOSD (5.4 % vs. 27.3 %, p = 0.043).

CONCLUSION

LO-NMOSD patients, particularly those who were AQP4-ab positive, had more severe functional impairments and poorer prognoses. The number of attacks in AQP4-ab(+) patients with EO-NMOSD was greater than that in AQP4-ab(+) patients with LO-NMOSD.

Brain and Spine Magnetic Resonance Imaging (MRI) Characteristics of a Pediatric Cohort With MOGAD

Background and ObjectivesMyelin-oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a recently defined demyelinating disorder with an age-related phenotypic spectrum. At disease onset, there is considerable clinical overlap between MOGAD and other demyelinating conditions, and it remains difficult to identify MOGAD radiographically. This study aims to further describe neuroimaging findings in the brain and the spine at presentation and throughout relapses in children with MOGAD.MethodsWe present a retrospective cohort study including all children presenting to a single center between 2010 and 2020 with acute demyelination who were positive for serum MOG-IgG antibodies and negative for serum aquaporin-4 antibodies. For each patient, magnetic resonance imaging (MRI) scans of the brain and spine at presentation and on each relapse were reviewed and categorized in a blinded fashion by 2 pediatric neuroradiologists.ResultsSixteen patients met the inclusion criteria. Four had diffuse and bilateral fluid-attenuated inversion recovery signal in the white matter, but only on initial presentation. The area postrema was never affected. All 5 patients with optic neuritis had pre-chiasmatic (but not chiasmatic) involvement on presentation. The brachium pontis was involved in 3 patients on initial presentation, and in 8 patients at any time. Eleven patients demonstrated spinal cord involvement, and the cervical, thoracic, and lumbar regions were involved at similar frequencies.DiscussionThe radiographic features of MOGAD in children appear to reflect their presenting demyelinating syndromes. However, certain features, such as diffuse fluid-attenuated inversion recovery hyperintensities and expansile fluid-attenuated inversion recovery signal in the brachium pontis, may be more frequent in MOGAD compared with other demyelinating disorders.

Smoking status and vascular risk factors as predictors of disability in AQP4-NMOSD and MOGAD

BACKGROUND

Smoking and vascular risk factors (VRFs) are reported to have adverse effects in multiple sclerosis but data are limited in aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD). This study aimed to measure their impact on disability.

METHODS

Smoking status was defined as never, past or current smokers and VRF comprised of ⩾1: hypertension, dyslipidemia, high body mass index or diabetes. Logistic regression models were fitted to predict their influence on recovery from onset attack and first optic neuritis (ON) attack.

RESULTS

A total of 442 patients were included. Current MOGAD smokers had a higher risk of disability from onset attack and first ON attack than never smokers (odds ratio (OR) 2.9, 95% confidence interval (CI) 1.3-6.9; OR 3.3, 95% CI 1.4-7.8). VRF in MOGAD was not predictive of disability. Current AQP4-NMOSD smokers and VRFs had a higher risk of residual disability from onset attacks (OR 7.5, 95% CI 2.1-27.7; OR 1.9, 95% CI 1.0-3.4). VRF was associated with higher risk of visual disability (OR 2.6, 95% CI 1.08-6.46) while smoking status was not.

CONCLUSIONS

Current smoking status detrimentally influenced onset attack recovery in AQP4-NMOSD and MOGAD patients, including visual recovery in MOGAD. Non-smoking VRFs influenced clinical and visual outcomes in AQP4-NMOSD.

Limited early IVIG for the treatment of pediatric myelin oligodendrocyte glycoprotein antibody-associated disease

BACKGROUND AND OBJECTIVES

This study aimed to evaluate whether a 6-month (limited) course of early IVIG is an effective strategy for relapse prevention in children with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) versus only acute therapies or other early immunotherapies.

METHODS

This was a retrospective multicenter observational study of pediatric MOGAD patients from the US Network of Pediatric Multiple Sclerosis Centers with disease onset between October 1996 and December 2022. Controls were matched to limited early IVIG subjects using a 3:1 ratio. Hazard ratios of time to relapse and rate ratios of annualized relapse rate were calculated. The cumulative probability of remaining relapse-free was evaluated with the Kaplan-Meier method.

RESULTS

We identified 130 unique control subjects treated before second attack with acute treatments only used in matching, 18 subjects treated with limited early IVIG, and 23 subjects treated with other early immunotherapy. The time to relapse was not different between either the limited early IVIG group and control group (HR 0.60 [0.22, 1.66], p = 0.32) or other early immunotherapy group (HR 0.98 [0.27, 3.6], p = 0.98). The limited early IVIG group showed a lower annualized relapse rate, although not statistically significant (RR 0.44 [0.17, 1.14], p = 0.09) compared with controls and a similar annualized relapse rate compared with the other early immunotherapy group (RR 0.56 [0.19, 1.69], p = 0.30).

DISCUSSION

Although underpowered, our results suggest that the use of a limited, 6-month course of early IVIG may reduce the risk of multiphasic disease in pediatric MOGAD.

Distinguishing Neuromyelitis Optica Spectrum Disorders Subtypes: A Study on AQP4 and C3d Epitope Expression in Cytokine-Primed Human Astrocytes

Neuromyelitis optica spectrum disorders (NMOSD) are severe autoimmune conditions affecting the central nervous system. In a subset of cases, no autoantibodies are detectable with the currently used routine assays. This study aimed to determine whether the levels of expression of aquaporin-4 (AQP4), excitatory amino acid transporter 2 (EAAT2), or complement C3/C3d and C5b-9 in human astrocytes following incubation with patient sera under inflammatory conditions differ between the various NMOSD subtypes and whether such differences can help to identify autoantibody-mediated cases of NMOSD. Levels of AQP4, EAAT2, complement C3/C3d and C5b-9 epitope expression on human astrocytes pretreated with various cytokines were quantitatively analyzed via indirect immunofluorescence after exposure to sera from patients with AQP4-IgG seropositive, MOG-IgG seropositive, and AQP4/MOG-IgG double seronegative NMOSD. Significant differences in AQP4 and C3d epitope expression were observed, with IL-17A, IL-10, and IL-6 pre-treatment notably influencing astrocytic responses. Using uniform manifold approximation and projection (UMAP), patients were classified into clusters corresponding to AQP4-IgG seropositive, MOG-IgG seropositive, or double seronegative NMOSD. These results demonstrate distinct astrocytic staining patterns across NMOSD subtypes, providing a potential diagnostic tool for distinguishing between autoantibody-mediated astrocytopathy and other cases. These findings suggest specific pathogenic mechanisms linked to each NMOSD subtype, which may have implications for tailoring therapeutic strategies based on cytokine involvement and astrocyte reactivity.

Role of soluble biomarkers in treating multiple sclerosis and neuroinflammatory conditions

Multiple sclerosis (MS) is a complex, chronic immune-mediated disease characterized by acute and progressive inflammatory damage of the central nervous system. MS manifests clinically with unpredictable neurological symptoms from focal inflammatory attacks as well as gradual neurodegeneration which contribute significantly to long-term disability progression. As treatment options advance, developing more personalized strategies capture heterogeneous mechanisms of injury which may be targeted or predict outcomes has been a focus of ongoing investigation. The role of soluble biomarkers has emerged as a pivotal tool to assist in these goals. Early promising candidates include neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP); these intermediate filaments that are expressed in neurons and astrocytes, respectively, are reliably measurable from blood samples and can reveal clinical and subclinical changes, as well as predict progression. Changes in these biomarkers can indicate a response to therapy, thus potentially be used as endpoints in clinical trials. Furthermore, recent research has identified a potential role of these and other soluble biomarkers in other neuroimmunological conditions including neuromyelitis spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein associated disease (MOGAD), autoimmune encephalitis, neurosarcoidosis, neuropsychiatric involvement in connective tissue disorders and vasculitides, and a host of neurodegenerative conditions. By integrating biomarker analysis into routine clinical assessments, healthcare providers may move toward a more nuanced and individualized care model, better equipped to meet the challenges posed by these multifaceted diseases. Understanding the dynamics of these biomarkers has many applications that can improve personalized medicine in MS.

Neuropsychological outcomes in pediatric MOGAD: clinical practice and future research

Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disorder (MOGAD) is a recently identified demyelinating condition affecting children and adults. Its impact on children's cognitive outcomes remains poorly understood but is a growing area of interest due to potential long-term implications. A systematic PubMed search was conducted to identify English-language studies that assessed cognition in individuals under 18 with MOGAD using neuropsychological tests, screening tools, or questionnaires. Children with MOGAD, particularly those with phenotypes such as AcuteDisseminated Encephalomyelitis (ADEM) and Neuromyelitis Optica SpectrumDisorder (NMOSD), often exhibit impairments in intellectual functioning, memory, processing speed, and working memory. However, some children maintain cognitive performance within the normal range. Cognitive difficulties are linked to disease relapses and may develop over time, although brain lesions do not consistently correlate with cognitive outcomes. Current studies, limited by small sample sizes, indicate that children with MOGAD are at risk for cognitive impairments. Regular neuropsychological monitoring is essential for pediatric MOGADpatients to identify and address cognitive challenges early, mitigating risks of academic and occupational underachievement. Multicentre multinational studies are needed to understand the cognitive profile of MOGAD better and assess the influence of disease-related variables on cognitive outcomes.

CD4-Positive T-Cell Responses to MOG Peptides in MOG Antibody-Associated Disease

To clarify T-cell responses in myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD), we cultured the peripheral blood mononuclear cells of 24 patients with MOGAD and 20 with aquaporin-4 (AQP4) antibody-positive neuromyelitis optica spectrum disorders (NMOSD), and those of 17 healthy controls (HCs), in the presence of fourteen MOG peptides covering the full-length MOG, five AQP4 peptides, two myelin basic protein peptides, or two proteolipid protein peptides. Then, we measured T-cell activation markers, such as cell surface CD69 and the intracellular production of granulocyte-macrophage colony-stimulating factor (GM-CSF) and interferon-γ in CD4-positive T-cells, with a flow cytometer. The expression of CD69 in response to MOG p16-40 and MOG p181-205 was significantly higher (Stimulation Index > 2) in MOGAD than in HCs. Also, CD69 for AQP4 p21-40, AQP4 p211-230, and MOG p166-190 were significantly increased in NMOSD than in HCs. Intracellular GM-CSF production responding to MOG p16-40 was significantly higher in MOGAD than in HCs (p < 0.05), although intracellular interferon-γ was not elevated. None of the responses to the other peptides were different between the groups. The present study showed subtle CD4-positive T-cell activation elicited by some MOG peptides alone in patients with MOGAD. Further studies of cytokines or other stimulation and alternative assay markers and metrics are needed to delineate the immunopathological roles of T-cells in MOGAD.

Neuroimmunology and Sleep

The immune system and sleep are inextricably linked in both health and pathological conditions. Tightly regulated neuroimmune processes are critical for the physiological maintenance of healthy sleep. Reciprocally, sleep disturbances can detrimentally affect immune homeostasis and predispose to increased risk of autoimmune conditions, which themselves are bidirectionally associated with a higher risk of sleep disturbances. Autoimmune diseases of the central nervous system (CNS), particularly conditions that affect neuroanatomical regions involved in sleep homeostasis and nocturnal respiration, are associated with an increased risk sleep disorders that may impact diagnosis, clinical course, and management. This review summarizes the bidirectional relationship between sleep and immunity and highlights several exemplar autoimmune conditions of the CNS that include sleep disorders as a consequence or diagnostic feature of the disorder.

Brain Volume Measures in Adults with MOG-Antibody-Associated Disease: A Longitudinal Multicenter Study

Background/Objectives: Little is known about the impact of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) on brain atrophy. This multicenter longitudinal study compares brain MRI volumes and T2 lesion volume between MOGAD patients, relapsing-remitting MS (RRMS) patients and a healthy control (HC) group with brain MRI scans available from an online repository. Methods: In total, 16 adult MOGAD patients (9 F) were age- and sex-matched with 44 RRMS patients (17 F) recruited in Verona MS Center and 14 HC subjects. The availability of two brain MRI scans performed 18 ± 6 months apart was mandatory for each patient. Annual percentage brain volume change (PBVC/y), baseline global brain, white matter (WM), gray matter (GM) regional brain volumes and T2 lesion volume were compared between groups. Results: PBVC/y was lower in MOGAD than in RRMS patients (p = 0.014) and lower in HC subjects than in MS patients (p = 0.005). Overall, MOGAD showed higher mean global brain (p = 0.012) and WM volume (p = 0.024) but lower median T2 lesion volume at timepoint 1 (p < 0.001); T2 lesion volume increased over time in the RRMS (p < 0.001) but not in the MOGAD cohort (p = 0.262). Conclusions: The structural brain MRI features of MOGAD show higher global brain and WM volumes and lower brain volume loss over time compared to RRMS, suggesting different underlining pathogenetic mechanisms.

Testing for myelin oligodendrocyte glycoprotein antibodies: Who, what, where, when, why, and how

Testing for myelin oligodendrocyte glycoprotein immunoglobulin G antibodies (MOG-IgG) is essential to the diagnosis of MOG antibody-associated disease (MOGAD). Due to its central role in the evaluation of suspected inflammatory demyelinating disease, the last 5 years has been marked by an abundance of research into MOG-IgG testing ranging from appropriate patient selection, to assay performance, to utility of serum titers as well as cerebrospinal fluid (CSF) testing. In this review, we synthesize current knowledge pertaining to the "who, what, where, when, why, and how" of MOG-IgG testing, with the aim of facilitating accurate MOGAD diagnosis in clinical practice.

Unravelling the clinical complexity of myelin oligodendrocyte glycoprotein antibody-associated acute disseminated encephalomyelitis in children: a comprehensive analysis

We present four different cases of acute disseminated encephalomyelitis (ADEM) within the Indian paediatric population. It is important to recognise how a single disease can manifest in various ways. Here, we emphasise the role of immunosuppression in treating ADEM. In all four cases, treatment was initiated based on clinical suspicion, even before confirming the demyelinating cause through laboratory or radiological tests. The degree of immunosuppression employed varied depending on the complexity of each case and their response to treatment. Case 1 demonstrated significant improvement in visual acuity after a 5-day course of high-dose methylprednisolone. In contrast, Case 4 represented a starkly different outcome, where despite undergoing therapeutic plasmapheresis, the disease remained uncontrollable, ultimately leading to the child's unfortunate demise. Cases 2 and 3 involved patients with severe clinical conditions necessitating intensive care and mechanical ventilation. They exhibited a remarkable response to immunosuppressive therapy, gradually regaining neurological function.

Serum Lipid Biomarkers for the Diagnosis and Monitoring of Neuromyelitis Optica Spectrum Disorder: Towards Improved Clinical Management

Background

Neuromyelitis optica spectrum disorder (NMOSD) is a group of immune-mediated disorders that often lead to severe disability. The diagnosis and monitoring of NMOSD can be challenging, particularly in seronegative cases, highlighting the need for reliable biomarkers to enhance clinical management. This study aimed to identify serum lipid biomarkers for the diagnosis and monitoring of NMOSD and to assess their potential to improve clinical decision-making.

Methods

We conducted a comprehensive serum proteomic analysis in a discovery cohort of NMOSD patients and controls to identify lipid-related proteins associated with NMOSD. Subsequently, we validated the candidate biomarkers in the retrospective cohort and developed diagnostic models using a random forest algorithm. The association between these lipid biomarkers and disease activity was further evaluated in longitudinal analysis.

Results

Our analysis identified a panel of serum lipid-related biomarkers that demonstrated significant differences between NMOSD patients and controls. The diagnostic models achieved the impressive accuracy of 72% for the full NMOSD spectrum, 72% for AQP4-IgG+ NMOSD, and 68% for double seronegative NMOSD. Importantly, these biomarkers showed a correlation with disease activity, with levels changing from relapse to remission. Additionally, a combination of these lipid biomarkers was found to predict relapse with the AUC of 0.861. A user-friendly smartphone application was developed to facilitate the straightforward "input-index, output-answer" screening process, enhancing both clinical decision-making and patient care.

Conclusion

The diagnostic model based on the serum lipid-related indexes (TC, TG, LDL, HDL, ApoA1, and ApoB) may be the useful tool for NMOSD in diagnosis and monitoring of disease stage, thereby improving the treatment outcome for patients. Future studies should focus on integrating these biomarkers into routine clinical practice to realize their full potential in enhancing NMOSD management.

Clinical characterization of diseases associated with anti-N-methyl-D-aspartate receptor encephalitis combined with anti-myelin oligodendrocyte glycoprotein antibodies in adults

OBJECTIVE

The aim of this study was to analyze the clinical characteristics of adult patients with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis combined with anti-myelin oligodendrocyte glycoprotein (MOG) antibodies.

METHODS

This was a non-randomized controlled study. Clinical data were collected from 17 patients with anti-NMDAR encephalitis combined with anti-MOG antibodies admitted to Xuanwu Hospital, Capital Medical University, from January 2020 to August 2024. As controls, 20 patients with NMDAR(+)/MOG(-) and 27 patients with MOG(+)/NMDAR(-) were selected.

RESULTS

The mean age of onset in the double-positive group was 33.47 ± 1.065 years, with a male-to-female ratio of 14:3. Significant differences were observed between the NMDAR(+)/MOG(+) group and the NMDAR(+)/MOG(-) group in terms of headache, lumbar puncture pressure, and cerebrospinal fluid (CSF) leukocyte counts (P < 0.05). Comparing the NMDAR(+)/MOG(+) group with the MOG(+)/NMDAR(-) group revealed significant differences in gender, headache, mental and behavioral abnormalities, limb twitching, loss of consciousness, cognitive impairment, speech impairment, visual impairment, limb numbness, cortical/sub-cortical white matter, brainstem lesions, OB type II, and CSF leukocyte counts (P < 0.05). No statistically significant differences were found in the comparison of CSF and serum antibody titers among the three groups (P > 0.05).

CONCLUSION

NMDAR and MOG antibodies can coexist in patients with autoimmune diseases, with a predominance of young male patients. The double-positive group exhibited more severe intracranial viral infections and a higher rate of intrathecal immunoglobulin synthesis in the central tissues. Compared to the double-positive group, NMDAR encephalitis alone presented with more similar clinical manifestations, while MOG-related disease demonstrated a higher likelihood of brainstem involvement.

The nomogram model predicts relapse risk in myelin oligodendrocyte glycoprotein antibody-associated disease: a single-center study

Background

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an autoimmune disorder of the central nervous system, characterized by seropositive MOG antibodies. MOGAD can present with a monophasic or relapsing course, where repeated relapses may lead to a worse prognosis and increased disability. Currently, little is known about the risk factors for predicting MOGAD relapse in a short period, and few established prediction models exist, posing a challenge to timely and personalized clinical diagnosis and treatment.

Methods

From April 2018 to December 2023, we enrolled 88 patients diagnosed with MOGAD at the First Hospital of Shanxi Medical University and collected basic clinical data. The data were randomly divided into a training cohort (80%) and a validation cohort (20%). Univariate logistic regression, least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression were used to identify independent risk factors for 1-year relapse. A prediction model was constructed, and a nomogram was developed. The receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate and internally validate model performance.

Results

Among 88 MOGAD patients, 29 relapsed within 1 year of onset (33%). A total of 4 independent risk factors for predicting relapse were identified: female sex (P=0.040), cortical encephalitis phenotype (P=0.032), serum MOG antibody titer ≥1:32 (P=0.007), and immunosuppressive therapy after the first onset (P= 0.045). The area under curve (AUC) value of the nomogram prediction model constructed with these four factors was 0.866 in the training cohort, and 0.864 in the validation cohort. The cutoff value of the total nomogram score was 140 points, distinguishing the low relapse risk group from the high relapse risk group (P < 0.001). The calibration curve demonstrated high consistency in prediction, and the DCA showed excellent net benefit in the prediction model. Tested by ROC curve, calibration curve, and DCA, the nomogram model also demonstrates significant value in predicting MOGAD relapse within 2 years.

Conclusion

The nomogram model we developed can help accurately predict the relapse risk of MOGAD patients within one year of onset and assist clinicians in making treatment decisions to reduce the chance of relapse.

Conformational Antibodies to Proteolipid Protein-1 and Its Peripheral Isoform DM20 in Patients With CNS Autoimmune Demyelinating Disorders

BACKGROUND AND OBJECTIVES

Antibodies to proteolipid protein-1 (PLP1-IgG), a major central myelin protein also expressed in the peripheral nervous system (PNS) as the isoform DM20, have been previously identified mostly in patients with multiple sclerosis (MS), with unclear clinical implications. However, most studies relied on nonconformational immunoassays and included few patients with non-MS CNS autoimmune demyelinating disorders (ADDs). We aimed to investigate conformational PLP1-IgG in the whole ADD spectrum.

METHODS

We devised a new live cell-based assay (CBA) for PLP1-IgG and used it to test 2 cohorts (retrospective exploratory, n = 284; prospective validation, n = 824) of patients with ADDs and controls (n = 177). Patients were classified as MS, neuromyelitis optica spectrum disorders (NMOSDs), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and other ADDs. PLP1-IgG-positive samples were tested for IgG subclasses, DM20-IgG, and on rat brain tissue-based assay (TBA). Complement-dependent cytotoxicity (CDC) was assessed on a live CBA and antigen specificity and conformational binding through immunoadsorption/colocalization/fixation experiments.

RESULTS

PLP1-IgG were found in 0 of 177 controls and 42 of 1104 patients with ADDs mainly diagnosed as other ADDs (19/42) with frequent myelitis/encephalomyelitis (14/19) and coexisting PNS involvement (13/19). Four of 19 patients with other ADDs fulfilled the seronegative NMOSD criteria. PLP1-IgG were also found in patients with MOGAD (11/42), more frequently with PNS involvement (p = 0.01), and in patients with MS (12/42), more frequently with atypical features (p < 0.001). PLP1-IgG-positive MOGAD had higher EDSS scores (p < 0.001) and PLP1-IgG-positive MS had higher severity scores (MSSS, p < 0.001) compared with those PLP1-IgG-negative. Overall, PLP1-IgG were found in 24.1% of patients with CNS+PNS-ADD, 21.2% with atypical MS, 8.3% with MOGAD, 12.0% with seronegative NMOSD, and 1.4% with typical MS. Their frequency within each diagnostic subgroup was consistent between the exploratory and validation cohorts. PLP1-IgG a) colocalized with their target on CBA-TBA, where their binding was abolished after immunoadsorption and fixation-induced conformational epitope alteration; b) mostly pertained to the IgG1/IgG3 subclass (68.3%) and were able to induce CDC; and c) coreacted with DM20 in all 12 patients with PNS involvement tested.

DISCUSSION

Conformational PLP1-IgG predominantly identify patients with non-MS ADDs. They should be tested mainly in those with CNS + PNS ADD, coherently with DM20-IgG coreactivity. PLP1-IgG could also be investigated as disease modifiers and prognostic markers in MS and MOGAD. Preliminary evidence supports their pathogenic potential.

Advances in Diagnosis and Management of Atypical Demyelinating Diseases

The last two decades have seen tremendous progress in understanding central nervous system (CNS) demyelinating diseases, heralding an exciting new era for the diagnosis and treatment of patients with a variety of non-multiple sclerosis neuroinflammatory diseases. This article comprehensively reviews atypical CNS demyelinating diseases, beginning with the general approach to CNS demyelination, continuing with suggestions to facilitate the initial evaluation, and followed by a discussion about specific diseases (neuromyelitis optica, myelin oligodendrocyte glycoprotein antibody disease, acute disseminated encephalomyelitis, iatrogenic CNS demyelination, and transverse myelitis). MRI examples of these disorders are provided to illustrate key radiographic findings. The article concludes with recommendations for treatment.

Neurite orientation dispersion and density imaging in myelin oligodendrocyte glycoprotein antibody-associated disease and neuromyelitis optica spectrum disorders

BACKGROUND

Aquaporin-4 antibody positive (AQP4+) neuromyelitis optica spectrum disorders (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) are two distinct antibody-mediated neuroinflammatory diseases. Diffusion Tensor Imaging (DTI) and Neurite Orientation Dispersion and Density Imaging (NODDI) are advanced diffusion-weighted MRI models providing quantitative metrics sensitive to cerebral microstructural changes. This study aims to differentiate brain tissue damage in NMOSD and MOGAD from controls and investigate its association with clinical disability, using NODDI and DTI-derived measures, including fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity.

METHODS

This study included 31 AQP4+ NMOSD, 21 MOGAD patients and 45 healthy controls. Clinical information included disease duration, Expanded Disability Status Scale (EDSS), Timed 25 Foot Walk test (T25FW), Nine-Hole Peg Test (9HPT), Symbol Digit Modalities Test (SDMT) and monocular 100 % high contrast visual acuity (HCVA). All participants underwent MRI scanning with multi-shell diffusion-weighted imaging, T2w fluid-attenuated inversion recovery and T1w magnetization prepared-rapid acquisition gradient echo sequences to obtain manually segmented T2-hyperintense white matter lesions (WML) and normal-appearing brain tissue (NABT) masks, including white matter (NAWM), cortical and deep gray matter (NACGM, NADGM). DTI and NODDI metrics were compared between groups using region-of-interest (ROI) analysis and tract-based spatial statistics. Tissue-weighted means were obtained for the NODDI metrics (weighted neurite density index, wNDI; weighted orientation dispersion index, wODI). Group differences in ROI analyses were assessed using age and sex adjusted linear regression models, followed by post-hoc comparisons with estimated marginal means. Stepwise multivariable linear regression models were used to evaluate the association between MRI biomarkers and clinical outcomes.

RESULTS

NMOSD patients had higher T2 lesion volume (1120.5 mm3 vs. 374.6 mm3, p<.001) and number (median 22 vs. 6, p<.001) than MOGAD patients. Both NMOSD and MOGAD lesions displayed lower wNDI and higher isotropic volume fraction (ISOVF) compared to microvascular lesions in controls (p<.05). In NACGM, NMOSD patients showed higher wODI but lower ISOVF compared to HC (p=.029). MOGAD patients had lower wNDI in NACGM compared to NMOSD (p=.012). Tract-based spatial statistics revealed damage to specific white matter abnormalities in NMOSD, with higher AD, ODI and ISOVF compared to controls, particularly in the corpus callosum and corticospinal tract. Clinical associations in NMOSD included higher EDSS with higher NAWM ISOVF (R2=0.46, p=.006), higher 9HPT with lower intralesional FA and higher NAWM MD (R2=0.54, p=.022), lower SDMT with lower intralesional FA and higher NACGM ISOVF (R2=0.54, p=.013), worse visual acuity with higher NAWM wODI. In MOGAD, higher EDSS was associated with lower NAWM FA (R2=0.29, p=.022), slower T25FW with higher NADGM ISOVF (R2=0.48, p<.001), lower SDMT with higher NAWM ISOVF (R2=0.62, p=.005) and worse visual acuity with higher NADGM MD.

CONCLUSION

NODDI and DTI measures are sensitive to pathological alterations in myelin and axon integrity, as water diffusion is less restricted in demyelinated tissue. Compared to MOGAD, patients with NMOSD tend to exhibit more extensive chronic white matter damage, demyelination or axonal injury. NODDI demonstrates greater sensitivity and specificity to alterations in NACGM compared to DTI. Given their association with clinical disability, NODDI metrics appear to be valuable neuroimaging biomarkers for assessing microstructural damage in clinical research.

Isolated Optic Neuritis: Etiology, Characteristics, and Outcomes in a US Mountain West Cohort

BACKGROUND

The diagnosis and treatment of autoimmune optic neuritis (ON) has improved with the accessibility and reliability of aquaporin-4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibody testing, yet autoantibody-negative ON remains common. This study describes the demographic, clinical, and outcome data in patients with isolated ON across the pediatric and adult cohort.

METHODS

A retrospective chart review of University of Utah Health patients with the International Classification of Diseases ( ICD ) code of ICD-9 377.30 (ON unspecified), ICD-9 377.39 (other ON), or ICD-10 H46 (ON) and at least 2 ophthalmologic evaluations were conducted between February 2011 and July 2023. Only isolated cases of ON without other brain or spinal demyelinating lesions were evaluated. Differences in demographic and clinical characteristics between AQP4, MOG, and Other-ON were determined.

RESULTS

Of the 98 patients (15 children and 83 adults), 9 (9.2%) were positive for AQP4-IgG and 35 (35.7%) tested positive for MOG-IgG. Fifty-four were classified into Other-ON, of which 7 (13.0%) had recurrence or new demyelinating lesions during a median follow-up of 12.5 months-2 were ultimately diagnosed with recurrent isolated ON (RION), 1 with chronic relapsing inflammatory ON (CRION), 2 with multiple sclerosis, 1 with collapsin response-mediator protein (CRMP)-5-ON, and 1 with seronegative neuromyelitis optica spectrum disorder. Four patients were treated with long-term immunosuppressive therapy. No patients with RION or CRION had preceding infections; they had first recurrences of ON within 2 months. At presentation, AQP4-ON (75%) and MOG-ON (48.8%) had more severe vision loss (visual acuity <20/200) than Other-ON (23.2%, P = 0.01). At the 1-month follow-up, 93.0% of patients with MOG-ON and 89.3% of patients with Other-ON demonstrated a visual acuity ≥20/40, compared with only 50% of patients with AQP4-ON ( P < 0.01). By the last follow-up, 37.5% of the AQP4-ON still exhibited visual acuity <20/40, including 25% who experienced severe vision loss (visual acuity <20/200). By contrast, over 95% of patients with MOG-ON and Other-ON maintained a visual acuity of ≥20/40. In our cohort, over a quarter of pediatric cases presented with simultaneous bilateral ON, 40% had a preceding infection, and 44.4% initially presented with a visual acuity <20/200. Two pediatric cases had recurrence, and both were MOG-ON. By their last follow-up, all pediatric cases had achieved a visual acuity of 20/40 or better. In addition, pediatric cases were more likely to exhibit disc edema compared with adult cases (100% vs 64%, P < 0.01).

CONCLUSIONS

Despite recent advances in identification and availability of testing for AQP4-IgG and MOG-IgG, over half of patients who presented with isolated ON remained with an "idiopathic" diagnostic label. As more than 1 in 10 patients with AQP4-IgG and MOG-IgG negative ON experienced recurrence or develop new demyelinating lesions, clinicians should provide anticipatory guidance and closely monitor for potential long-term outcomes. In addition, it is crucial to re-evaluate the diagnosis in cases of poor recovery, ON recurrence, and the emergence of new neurological symptoms, as ON can often be the initial presentation of other conditions.

Autoimmune encephalitis with dizziness in children: A case report presented to the otolaryngology department

RATIONALE

Motion sickness is frequently encountered condition, characterized primarily by symptoms such as nausea, vomiting, headache, dizziness, and drowsiness. Autoimmune encephalitis refers to a group of diseases that can present with a variety of clinical symptoms according to the expressed autoantigen. One of the rare types is myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). Herein, we report the case of a child who presented to our otolaryngology department with a diagnosis of motion sickness but was eventually diagnosed with MOGAD. To our knowledge, this is the first such case reported in the literature.

PATIENT CONCERNS

An 11-year-old boy presented to a vertigo clinic with the primary complaints of dizziness, occasional nausea, and vomiting after traveling with his family for 3 days. He was diagnosed with motion sickness and was administered oral betastine mesylate tablets (6 mg, 3 times/d for 3 days). The dizziness resolved after 3 days of medication. However, 1 week later, the child developed symptoms of vision loss, poor mental performance, and sluggish responses.

DIAGNOSIS

The patient was diagnosed with MOGAD.

INTERVENTIONS

The patient was treated with human immunoglobulin (2 g/kg, divided into 3 doses), mannitol, and a high dose of methylprednisolone succinate (20 mg/kg for 3 consecutive days). The dose of methylprednisolone succinate was then gradually tapered over 18 days.

OUTCOMES

After 15 days of treatment, the child's vision in the left eye improved, with visual acuity returned to 0.25. His sense of taste and pain in the left limb returned to normal, his mental responses were good, and no antinuclear antibodies were detectable.

LESSONS

Although most childhood episodes of dizziness are benign, it is important for clinicians to remain vigilant for the possibility of central nervous system disease as the underlying cause. When the diagnosis is uncertain, doctors and parents must closely monitor affected children to avoid misdiagnosis and treatment delays.

Phenotype of Relapsing Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease in Children

BACKGROUND AND PURPOSE

To determine the clinical phenotypes, relapse timing, treatment responses, and outcomes of children with relapsing myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD).

METHODS

We collected the demographic, clinical, laboratory, and radiological data of patients aged <18 years who had been diagnosed with MOGAD at Seoul National University Children's Hospital between January 2010 and January 2022; 100 were identified as positive for MOG antibodies, 43 of whom experienced relapse.

RESULTS

The median age at onset was 7 years (range 2-16 years). The median number of relapses was 2 (range 1-8), and patients were followed up for a median of 65 months (range 5-214 months). The first relapse was experienced before 3 months from onset by 15 patients (34.9%). The most-common initial phenotypes were acute disseminated encephalomyelitis (n=17, 39.5%) and optic neuritis (ON; n=11, 25.6%). The most-common relapse phenotypes were neuromyelitis optica spectrum disorder (n=9, 20.9%), relapsing ON (n=6, 14.0%), and multiphasic disseminated encephalomyelitis (n=6, 14.0%). Many of the patients (n=18, 41.9%) were not specifically categorized. A high proportion of these patients had non-acute disseminated encephalomyelitis encephalitis. Atypical phenotypes such as prolonged fever or hemiplegic migraine-like episodes were also noted. Mycophenolate mofetil and cyclic immunoglobulin treatment significantly reduced the annual relapse rates.

CONCLUSIONS

Our 43 pediatric patients with relapsing MOGAD showed a tendency toward early relapse and various relapse phenotypes. The overall prognoses of these patients were good regardless of phenotype or response to second-line immunosuppressant treatment.

Human microbiome-derived peptide affects the development of experimental autoimmune encephalomyelitis via molecular mimicry

BACKGROUND

Gut commensal microbiota has been identified as a potential environmental risk factor for multiple sclerosis (MS), and numerous studies have linked the commensal microorganism with the onset of MS. However, little is known about the mechanisms underlying the gut microbiome and host-immune system interaction.

METHODS

We employed bioinformatics methodologies to identify human microbial-derived peptides by analyzing their similarity to the MHC II-TCR binding patterns of self-antigens. Subsequently, we conducted a range of in vitro and in vivo assays to assess the encephalitogenic potential of these microbial-derived peptides.

FINDINGS

We analyzed 304,246 human microbiome genomes and 103 metagenomes collected from the MS cohort and identified 731 nonredundant analogs of myelin oligodendrocyte glycoprotein peptide 35-55 (MOG35-55). Of note, half of these analogs could bind to MHC II and interact with TCR through structural modeling of the interaction using fine-tuned AlphaFold. Among the 8 selected peptides, the peptide (P3) shows the ability to activate MOG35-55-specific CD4+ T cells in vitro. Furthermore, P3 shows encephalitogenic capacity and has the potential to induce EAE in some animals. Notably, mice immunized with a combination of P3 and MOG35-55 develop severe EAE. Additionally, dendritic cells could process and present P3 to MOG35-55-specific CD4+ T cells and activate these cells.

INTERPRETATION

Our data suggests the potential involvement of a MOG35-55-mimic peptide derived from the gut microbiota as a molecular trigger of EAE pathogenesis. Our findings offer direct evidence of how microbes can initiate the development of EAE, suggesting a potential explanation for the correlation between certain gut microorganisms and MS prevalence.

FUNDING

National Natural Science Foundation of China (82371350 to GY).

Challenges in the Diagnosis and Management of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD)

Myelin oligodendrocyte glycoprotein antibody-associated disease has been recently identified to be a distinct autoimmune central nervous system disorder. There is significant clinical and radiological overlap with multiple sclerosis and aquaporin-4-IgG-associated neuromyelitis optica spectrum disorders. Clinical course is variable in that patients may have a monophasic or relapsing course, disease severity is unpredictable, and unlike other idiopathic autoimmune inflammatory disorders, there is no gender predilection and it is more likely to affect pediatric population. There are no clear-cut treatment guidelines. Duration and dose of oral steroids after the first attack, role of immunosuppressants in relapsing disease, and duration of therapy for the latter are not certain. Currently, there are no disease-specific therapies available, though some novel therapies are under trial. Some of these challenges will be addressed in this paper.

MOG-IgG is rare in AQP4-IgG seronegative NMO phenotype in Brazil

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune disease most frequently characterized by a neuromyelitis optica (NMO) phenotype, comprising both simultaneous or sequential optic neuritis (ON) and longitudinally extensive transverse myelitis (LETM). Symptoms of brainstem, diencephalic and cerebral involvement may also occur. While most NMOSD patients test positive for serum aquaporin-4 (AQP4) antibodies, some seronegative patients test positive for oligodendrocyte glycoprotein-IgG (MOG-IgG). Early identification of seropositive MOG-IgG seropositive patients among those with AQP4-IgG seronegative NMO phenotype may impact disease treatment and outcome.

OBJECTIVE

To determine the frequency of MOG-IgG in patients with AQP4-IgG seronegative NMO phenotype at a single reference center in Brazil and to analyze factors influencing their identification.

METHODS

A retrospective review of medical records of patients who presented with NMO phenotype and met the 2015 IPND criteria for NMOSD without AQP4 antibodies was conducted in a single center in Brazil. Patients were tested for serum AQP4 antibodies and retrospectively for MOG-IgG using cell-based assays. In addition to demographic, clinical, and imaging data, information on time intervals between disease onset and MOG-IgG testing, as well as the most recent relapse to MOG-IgG testing, was collected.

RESULTS

Out of 118 patients tested for MOG-IgG, 28 (23.7 %) presented with NMO phenotype and met the 2015 IPND criteria for NMOSD without AQP4-IgG. Three (10.7 %) of them tested positive for MOG-IgG serostatus. All were females and had a median age of 26 (11-34) years at disease presentation. The median disease duration was 11.2 yrs. Two patients had a relapsing course. Optic neuritis, myelitis, and brainstem syndrome were the most common presenting symptoms. The median annualized relapse rate was 0.25, and the median EDSS score at the most recent visit was 2.0 (1.5-5.0). There were 25 double seronegative patients, 21 (84 %) of whom were female and non-Caucasian; the median age at disease onset was 30 years (2-60), and the median EDSS at most recent visit was 4.0 (0 - 8.0).

DISCUSSION

The study identified MOG-IgG antibodies in 10.7 % of a cohort with AQP4-IgG seronegative NMO phenotype. Immunosuppressive treatment and long intervals between disease attacks and antibody testing may have impacted the frequency of MOG-IgG seropositivity. As MOG-IgG testing is crucial for diagnosing MOGAD in AQP4-IgG seronegative NMO phenotype, we highlight the need for broader and timely testing to improve diagnostic accuracy in resource-limited settings.

Predictors of a relapsing course in myelin oligodendrocyte glycoprotein antibody-associated disease

BACKGROUND

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a recently described demyelinating disorder, and children represent about 50% of all cases. Almost half of the patients experience relapses, but very few studies have evaluated predictors of relapse risk, challenging clinical management. The study aimed to identify predictors at MOGAD onset that are associated with a relapsing course.

METHODS

Prospectively collected data from paediatric patients with MOGAD seen by the US Network of Paediatric MS Centres were leveraged. Univariable and adjusted multivariable models were used to predict recurrent disease.

RESULTS

We identified 326 MOGAD cases (mean age at first event 8.9 years [SD 4.3], 57% female, 77% white and 74% non-Hispanic) and 46% relapsed during a mean follow-up of 3.9 years (SD 4.1). In the adjusted multivariable model, female sex (HR 1.66, 95% CI 1.17 to 2.36, p=0.004) and Hispanic/Latino ethnicity (HR 1.77, 95% CI 1.19 to 2.64, p=0.005) were associated with a higher risk of relapsing MOGAD. Maintenance treatment initiated before a second event with rituximab (HR 0.25, 95% CI 0.07 to 0.92, p=0.037) or intravenous immunoglobulin (IVIG) (HR 0.35, 95% CI 0.14 to 0.88, p=0.026) was associated with lower risk of a second event in multivariable analyses. Conversely, maintenance steroids were associated with a higher estimated relapse risk (HR 1.76, 95% CI 0.90 to 3.45, p=0.097).

CONCLUSION

Sex and ethnicity are associated with relapsing MOGAD. Use of rituximab or IVIG therapy shortly after onset is associated with a lower risk of the second event. Preventive treatment after a first event could be considered for those with a higher relapse risk.

MOGAD and NMOSD: insights on patients' radiological and laboratory findings from a single UAE center

Introduction

Although neuromyelitis optica spectrum disorders (NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD) are rare diseases, they pose a significant burden on both society and the healthcare system. This study aims to discuss the demographics and patient characteristics of these diseases in a single center in the United Arab Emirates (UAE).

Methods

This is a retrospective, descriptive study that included patients with either NMOSD or MOGAD treated at Rashid Hospital, UAE during the period between January 2019 and January 2024. Patients were selected and categorized according to NMOSD criteria, aquaporin-4 antibodies, and MOG antibodies. Patient demographics, clinical characteristics, and medical history were retrieved from their medical records and descriptively analyzed in the light of patients' serological data.

Results

We identified 34 patients with non-multiple sclerosis atypical CNS inflammatory/demyelinating syndromes. Twenty-seven patients (79.4%) fulfilled the criteria for NMOSD, while seven (20.6%) tested positive for MOG antibodies, fulfilling the criteria for MOGAD. In the NMOSD cohort, 19% (n = 5) were AQP4-antibody negative. Seventy-four percent of the NMOSD cohort and 43% of the MOGAD cohort were female. For MOGAD patients, disease onset was at a younger age (median onset age of 25 years) compared to the overall study population (mean onset age of 28.94 years). Long segment transverse myelitis was only detected in NMOSD patients (33.3%), and brainstem syndrome with area postrema syndrome was more common in the MOGAD cohort (29% vs. 4%). The rate of positive response to intravenous methylprednisolone as initial therapy was comparable across both cohorts (74% in case of NMOSD and 71% in case of MOGAD).

Conclusion

This study provides valuable insights into the status of NMOSD and MOGAD in the UAE, highlighting the need for larger, prospective studies to further characterize these diseases in the local population, as well as the need for improved understanding of the epidemiology and management of these rare but debilitating conditions.

Turncoat antibodies unmasked in a model of autoimmune demyelination: from biology to therapy

Autoantibodies contribute to many autoimmune diseases, yet there is no approved therapy to neutralize them selectively. A popular mouse model, experimental autoimmune encephalomyelitis (EAE), could serve to develop such a therapy, provided we can better understand the nature and importance of the autoantibodies involved. Here we report the discovery of autoantibody-secreting extrafollicular plasmablasts in EAE induced with specific myelin oligodendrocyte glycoprotein (MOG) antigens. Single-cell RNA sequencing reveals that these cells produce non-affinity-matured IgG antibodies. These include pathogenic antibodies competing for shared binding space on MOG's extracellular domain. Interestingly, the synthetic anti-MOG antibody 8-18C5 can prevent the binding of pathogenic antibodies from either EAE mice or people with MOG antibody disease (MOGAD). Moreover, an 8-18C5 variant carrying the NNAS mutation, which inactivates its effector functions, can reduce EAE severity and promote functional recovery. In brief, this study provides not only a comprehensive characterization of the humoral response in EAE models, but also a proof of concept for a novel therapy to antagonize pathogenic anti-MOG antibodies.

Biomarkers for neuromyelitis optica: a visual analysis of emerging research trends

Neuromyelitis optica is an inflammatory demyelinating disease of the central nervous system that differs from multiple sclerosis. Over the past 20 years, the search for biomarkers for neuromyelitis optica has been ongoing. Here, we used a bibliometric approach to analyze the main research focus in the field of biomarkers for neuromyelitis optica. Research in this area is consistently increasing, with China and the United States leading the way on the number of studies conducted. The Mayo Clinic is a highly reputable institution in the United States, and was identified as the most authoritative institution in this field. Furthermore, Professor Wingerchuk from the Mayo Clinic was the most authoritative expert in this field. Keyword analysis revealed that the terms "neuromyelitis optica" (261 times), "multiple sclerosis" (220 times), "neuromyelitis optica spectrum disorder" (132 times), "aquaporin 4" (99 times), and "optical neuritis" (87 times) were the most frequently used keywords in literature related to this field. Comprehensive analysis of the classical literature showed that the majority of publications provide conclusive research evidence supporting the use of aquaporin-4-IgG and neuromyelitis optica-IgG to effectively diagnose and differentiate neuromyelitis optica from multiple sclerosis. Furthermore, aquaporin-4-IgG has emerged as a highly specific diagnostic biomarker for neuromyelitis optica spectrum disorder. Myelin oligodendrocyte glycoprotein-IgG is a diagnostic biomarker for myelin oligodendrocyte glycoprotein antibody-associated disease. Recent biomarkers for neuromyelitis optica include cerebrospinal fluid immunological biomarkers such as glial fibrillary acidic protein, serum astrocyte damage biomarkers like FAM19A5, serum albumin, and gamma-aminobutyric acid. The latest prospective clinical trials are exploring the potential of these biomarkers. Preliminary results indicate that glial fibrillary acidic protein is emerging as a promising candidate biomarker for neuromyelitis optica spectrum disorder. The ultimate goal of future research is to identify non-invasive biomarkers with high sensitivity, specificity, and safety for the accurate diagnosis of neuromyelitis optica.

Extensive brainstem lesions in myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD): A case report

Myelin oligodendrocyte glycoprotein antibody-associated disease is a group of central nervous system demyelinating disorders caused by autoantibodies. While myelin oligodendrocyte glycoprotein antibody-associated disease typically presents as optic neuritis and myelitis in adults, this case report details a patient with brainstem lesions. A 45-year-old male presented with episodes of vertigo, nystagmus, and diplopia in left lateral gaze, which had persisted for 2 months, accompanied by headache. Computed tomography showed hyperdensity extending from the left side of the pons to the middle cerebellar peduncle. Magnetic resonance imaging revealed lesions exhibiting heterogeneous diffusion restriction, with enhancement that included granular and linear patterns. 18F-fluorodeoxyglucose positron emission tomography demonstrated increased uptake in these lesions. Following further evaluation, myelin oligodendrocyte glycoprotein antibody-associated disease was diagnosed. Treatment with high-dose corticosteroids initially alleviated symptoms, but symptoms flared upon reduction of the steroids. This case underscores the importance of considering myelin oligodendrocyte glycoprotein antibody-associated disease in the differential diagnosis of brainstem lesions and discusses distinguishing imaging features from similar conditions.

Clinical, prognostic and pathophysiological implications of MOG-IgG detection in the CSF: the importance of intrathecal MOG-IgG synthesis

BACKGROUND

Cerebrospinal fluid myelin oligodendrocyte glycoprotein IgG (CSF MOG-IgG) are found in a proportion of patients with MOG antibody-associated disorder (MOGAD) and have been associated with severe disease presentations. However, most studies did not systematically investigate the role of MOG-IgG intrathecal synthesis (ITS).

METHODS

We retrospectively studied 960 consecutive patients with paired serum and CSF samples screened for MOG-IgG using a live cell-based assays. MOG-IgG-specific antibody index (AIMOG) was systematically calculated using serum and CSF titres to assess MOG-IgG ITS, and clinical features were compared between MOG-IgG CSF+/CSF- and ITS+/ITS- patients.

RESULTS

MOG-IgG were found in 55/960 patients (5.7%; serum+/CSF-: 58.2%, serum+/CSF+: 34.5%; serum-/CSF+: 7.3%). Serum/CSF MOG-IgG titres showed a moderate correlation in patients without ITS (ρ=0.47 (CI 0.18 to 0.68), p<0.001), but not in those with ITS (ρ=0.14 (CI -0.46 to -0.65), p=0.65). There were no clinical-paraclinical differences between MOG-IgG CSF+ vs CSF- patients. Conversely, patients with MOG-IgG ITS showed pyramidal symptoms (73% vs 32%, p=0.03), spinal cord involvement (82% vs 39%, p=0.02) and severe outcome at follow-up (36% vs 5%, p=0.02) more frequently than those without MOG-IgG ITS. A multivariate logistic regression model indicated that MOG-IgG ITS was an independent predictor of a poor outcome (OR: 14.93 (CI 1.40 to 19.1); p=0.03). AIMOG correlated with Expanded Disability Status Scale (EDSS) scores at disease nadir and at last follow-up (p=0.02 and p=0.01).

CONCLUSIONS

Consistently with physiopathology, MOG-IgG ITS is a promising prognostic factor in MOGAD, and its calculation could enhance the clinical relevance of CSF MOG-IgG testing, making a case for its introduction in clinical practice.

Distinct virtual histology of grey matter atrophy in four neuroinflammatory diseases

Grey matter (GM) atrophies are observed in multiple sclerosis, neuromyelitis optica spectrum disorders [NMOSD; both anti-aquaporin-4 antibody-positive (AQP4+) and -negative (AQP4-) subtypes] and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). Revealing the pathogenesis of brain atrophy in these disorders would help their differential diagnosis and guide therapeutic strategies. To determine the neurobiological underpinnings of GM atrophies in multiple sclerosis, AQP4+ NMOSD, AQP4- NMOSD and MOGAD, we conducted a virtual histology analysis that links T1-weighted image derived GM atrophy and gene expression using a multicentre cohort of 324 patients with multiple sclerosis, 197 patients with AQP4+ NMOSD, 75 patients with AQP4- NMOSD, 47 patients with MOGAD and 2169 healthy control subjects. First, interregional GM atrophy profiles across the cortical and subcortical regions were determined using Cohen's d between patients with multiple sclerosis, AQP4+ NMOSD, AQP4- NMOSD or MOGAD and healthy controls. The GM atrophy profiles were then spatially correlated with the gene expression levels extracted from the Allen Human Brain Atlas, respectively. Finally, we explored the virtual histology of clinical-feature relevant GM atrophy using a subgroup analysis that stratified by physical disability, disease duration, number of relapses, lesion burden and cognitive function. Multiple sclerosis showed a severe widespread GM atrophy pattern, mainly involving subcortical nuclei and brainstem. AQP4+ NMOSD showed an obvious widespread pattern of GM atrophy, predominately located in occipital cortex as well as cerebellum. AQP4- NMOSD showed a mild widespread GM atrophy pattern, mainly located in frontal and parietal cortices. MOGAD showed GM atrophy mainly involving the frontal and temporal cortices. High expression of genes specific to microglia, astrocytes, oligodendrocytes and endothelial cells in multiple sclerosis, S1 pyramidal cells in AQP4+ NMOSD, as well as S1 and CA1 pyramidal cells in MOGAD, had spatial correlations with GM atrophy profile, while no atrophy profile-related gene expression was found in AQP4- NMOSD. Virtual histology of clinical feature-relevant GM atrophy pointed mainly to the shared neuronal and endothelial cells, among the four neuroinflammatory diseases. The unique underlying virtual histology patterns were microglia, astrocytes and oligodendrocytes for multiple sclerosis; astrocytes for AQP4+ NMOSD; and oligodendrocytes for MOGAD. Neuronal and endothelial cells were shared potential targets across these neuroinflammatory diseases. These findings may help the differential diagnoses of these diseases and promote the use of optimal therapeutic strategies.

Clinical characteristics analysis of 24 cases of pediatric MOG antibody-associated diseases

OBJECTIVE

To investigate the clinical characteristics of children with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD).

METHODS

A retrospective analysis was conducted on the clinical data, antibody tests, imaging, and factors associated with recurrence in 24 children diagnosed with MOGAD at Wuxi Children's Hospital from December 2017 to December 2023.

RESULTS

Among the 24 included children, the clinical characteristics at the onset of the first episode included fever (12 cases), headache (8), decreased vision (7), drowsiness (6), convulsions (5), ataxia (3), paralysis of both lower limbs (2), urinary and fecal incontinence (2), and central facial palsy (1). Among them, one case started with paralysis of both lower limbs and urinary retention, and electromyography suggested the involvement of peripheral nerves, leading to the diagnosis of MOG antibody-associated central and peripheral demyelinating syndrome (MOGAD-CCPD). Cranial MRI abnormalities were observed in 20 children, and spinal MRI abnormalities were noted in 6 children. All children responded well to corticosteroids and intravenous immunoglobulin, but 7 children experienced a relapse. Among them, 3 children achieved disease control after the addition of mycophenolate mofetil (CellCept), with no further relapses observed during follow-up.

CONCLUSION

The disease course of MOGAD can be monophasic or relapsing. Most children have a good response to acute phase treatments. For those who relapse, immunosuppressants can be added as maintenance therapy, and the clinical prognosis is generally good. This article reports the first highly rare case in China of MOGAD-CCPD in childhood, suggesting that MOG IgG may serve as a potential biomarker associated with CCPD.

Clinical Spectrum of Ophthalmic Manifestations in Myelin Oligodendrocyte Glycoprotein-Associated Disease (MOGAD): A Comprehensive Case Report

PURPOSE

To describe diverse ocular manifestations in a patient with Myelin oligodendrocyte glycoprotein-associated disease (MOGAD).

METHODS

A 15-year-old Indian male had severe loss of vision in one eye, followed by a recurrent attack of optic neuritis in the fellow eye a few weeks later. He had a history of vision loss, speech disturbances, altered sensorium and was a confirmed case of Myelin oligodendrocyte glycoprotein-associated disease (MOGAD). Apart from optic neuritis, other rare ophthalmic associations, namely, macular neuroretinopathy, retinal haemorrhages, severe optic nerve head edema, peri neuritis, and orbital enhancement on magnetic resonance imaging (MRI) were noted.

RESULTS

He responded dramatically to treatment with intravenous pulse steroids and relapses were controlled with long-term immunomodulation therapy.

CONCLUSION

This case report reiterates the need for early treatment with pulse steroids in MOGAD and depicts the heterogeneous involvement of various ocular structures in the disease.

Predicting the future of autoimmune encephalitides

The concept that many neurologic and psychiatric disorders of unknown cause are immune-mediated has evolved fast during the past 20 years. The main contribution to the expansion of this field has been the discovery of antibodies that attack neuronal or glial cell-surface proteins or receptors, directly modifying their structure and function. These antibodies facilitate the diagnosis and prompt treatment of patients who often improve with immunotherapy. The identification of this group of diseases, collectively named "autoimmune encephalitides", was preceded by many years of investigations on other autoimmune CNS disorders in which the antibodies are against intracellular proteins, occur more frequently with cancer, and associate with cytotoxic T-cell responses that are less responsive to immunotherapy. Here, we first trace the recent history of the autoimmune encephalitides and address how to assess the clinical value and implement in our practice the rapid pace of autoantibody discovery. In addition, we review recent developments in the post-acute stage of the two main autoimmune encephalitides (NMDAR and LGI1) focusing on symptoms that are frequently overlooked or missed, and therefore undertreated. Because a better understanding of the pathophysiology of these diseases relies on animal models, we examine currently available studies, recognizing the existing needs for better and all-inclusive neuro-immunobiological models. Finally, we assess the status of biomarkers of disease outcome, clinical scales, current treatment strategies, and emerging therapies including CAR T-cell technology. Altogether, this overview is intended to identify gaps of knowledge and provide suggestions for improvement and insights for future research.

Time to Treat First Acute Attack of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease

Importance

A proportion of people with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) have a relapsing disease course and persistent anti-myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG) seropositivity. Few studies have investigated whether treatment of the first MOGAD attack is associated with the long-term disease course and/or MOG-IgG seronegative conversion.

Objective

To investigate the association of time to treat the first acute MOGAD attack with relapse risk and MOG-IgG serostatus.

Design, Setting, and Participants

This was a retrospective, nationwide, multicenter cohort study involving 14 secondary or tertiary hospitals in South Korea between November 2009 and August 2023. People with adult-onset MOGAD, who either had a relapse or were followed up for more than 12 months after disease onset and had a detailed medical record of their first attack, were included. Individuals were excluded for adolescent-onset MOGAD or short disease duration.

Exposures

Patients were categorized based on the time to treat the first acute MOGAD attack: early (<5 days), intermediate (5-14 days), and late (not treated within 14 days).

Main Outcomes and Measures

A multivariable analysis for clinical and treatment factors associated with relapsing disease course and/or MOG-IgG seronegative conversion. Further subgroup analyses were conducted among those without long-term nonsteroidal immunosuppressant (NSIS) maintenance treatment.

Results

Among the 315 individuals screened, 75 were excluded. A total of 240 patients (median [IQR] age at onset, 40.4 [28.8-56.1] years; 125 female [52.1%]) with median (IQR) disease duration of 3.07 (1.95-6.15) years were included. A total of 110 of 240 patients (45.8%) relapsed after a median (IQR) of 0.45 (0.18-1.68) years, and 29 of 116 patients (25.0%) experienced a conversion to seronegative MOG-IgG. Both the time to treatment of the first MOGAD attack (late vs early: adjusted hazard ratio [aHR], 2.64; 95% CI, 1.43-4.84; P = .002; intermediate vs early: aHR, 2.02; 95% CI, 1.10-3.74; P = .02) and NSIS maintenance treatment (aHR, 0.24; 95% CI, 0.14-0.42; P < .001) were independently associated with the risk of relapse. In a subgroup without NSIS maintenance, the time to treat of the first MOGAD attack was still associated with higher risk of relapse (late vs early: aHR, 3.51; 95% CI, 1.64-7.50; P = .001; intermediate vs early: aHR, 2.68; 95% CI, 1.23-5.85; P = .01). Lastly, the time to treat of the first MOGAD attack was also associated with MOG-IgG seronegative conversion (early vs late: adjusted odds ratio, 7.04; 95% CI, 1.58-31.41; P = .01), whereas NSIS maintenance treatment was not.

Conclusions and Relevance

Results of this cohort study suggest that early treatment of the first acute MOGAD attack was associated with a reduction in the proportion of relapsing disease course and an increase in the likelihood of MOG-IgG seronegative conversion. These data suggest that timing of acute phase treatment for the first MOGAD attack can be associated with the long-term prognosis and autoimmune status of patients.

NMOSD and MOGAD: an evolving disease spectrum

Neuromyelitis optica (NMO) spectrum disorder (NMOSD) is a relapsing inflammatory disease of the CNS, characterized by the presence of serum aquaporin 4 (AQP4) autoantibodies (AQP4-IgGs) and core clinical manifestations such as optic neuritis, myelitis, and brain or brainstem syndromes. Some people exhibit clinical characteristics of NMOSD but test negative for AQP4-IgG, and a subset of these individuals are now recognized to have serum autoantibodies against myelin oligodendrocyte glycoprotein (MOG) - a condition termed MOG antibody-associated disease (MOGAD). Therefore, the concept of NMOSD is changing, with a disease spectrum emerging that includes AQP4-IgG-seropositive NMOSD, MOGAD and double-seronegative NMOSD. MOGAD shares features with NMOSD, including optic neuritis and myelitis, but has distinct pathophysiology, clinical profiles, neuroimaging findings (including acute disseminated encephalomyelitis and/or cortical encephalitis) and biomarkers. AQP4-IgG-seronegative NMOSD seems to be a heterogeneous condition and requires further study. MOGAD can manifest as either a monophasic or a relapsing disease, whereas NMOSD is usually relapsing. This Review summarizes the history and current concepts of NMOSD and MOGAD, comparing epidemiology, clinical features, neuroimaging, pathology and immunology. In addition, we discuss new monoclonal antibody therapies for AQP4-IgG-seropositive NMOSD that target complement, B cells or IL-6 receptors, which might be applied to MOGAD in the near future.

The influence of MOGAD on diagnosis of multiple sclerosis using MRI

Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) is an immune-mediated demyelinating disease that is challenging to differentiate from multiple sclerosis (MS), as the clinical phenotypes overlap, and people with MOGAD can fulfil the current MRI-based diagnostic criteria for MS. In addition, the MOG antibody assays that are an essential component of MOGAD diagnosis are not standardized. Accurate diagnosis of MOGAD is crucial because the treatments and long-term prognosis differ from those for MS. This Expert Recommendation summarizes the outcomes from a Magnetic Resonance Imaging in MS workshop held in Oxford, UK in May 2022, in which MS and MOGAD experts reflected on the pathology and clinical features of these disorders, the contributions of MRI to their diagnosis and the clinical use of the MOG antibody assay. We also critically reviewed the literature to assess the validity of distinctive imaging features in the current MS and MOGAD criteria. We conclude that dedicated orbital and spinal cord imaging (with axial slices) can inform MOGAD diagnosis and also illuminate differential diagnoses. We provide practical guidance to neurologists and neuroradiologists on how to navigate the current MOGAD and MS criteria. We suggest a strategy that includes useful imaging discriminators on standard clinical MRI and discuss imaging features detected by non-conventional MRI sequences that demonstrate promise in differentiating these two disorders.

Study of seasonality of attacks in MOG antibody-associated disease

BACKGROUND

Seasonal variation in attacks of acute disseminated encephalomyelitis (ADEM1) is reported in some studies. Myelin oligodendrocyte glycoprotein (MOG) antibodies are found in up to 50 % of ADEM cases. Despite this, there has been no adequately powered study of seasonality in MOG antibody-associated disease (MOGAD). We sought to determine whether there was an effect of season on incidence of total attacks and onset attacks of MOGAD.

METHODS

We searched the large national Oxford-based NMO Service database to identify attacks of MOGAD occurring between 2010 and 2021. Month of each attack was extracted and Edwards' test of seasonal variation was applied to determine whether there was a seasonal effect on total attacks and onset attacks.

RESULTS

Neither incidence of total attacks nor incidence of onset attacks varied significantly by month.

CONCLUSION

There is no evidence of seasonal fluctuations in the incidence of MOGAD attacks in the UK.

Infections Combined With Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease: A Case Report and Systematic Review of the Literature

Myelinating oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an immune-mediated inflammatory demyelinating disease of the central nervous system. Its specific etiology and pathogenesis remain unclear. In recent years, there have been increasing reports of MOGAD occurring after infections. Even cases of concurrent infection and MOGAD have been documented. We report a clinical case of a 14-year-old male patient admitted to the hospital with a fever and loss of consciousness. He underwent thorough medical examinations. The results of second-generation sequencing of the metagenome of the cerebrospinal fluid revealed that he was infected with Haemophilus parainfluenzae, and serum testing showed positive MOG antibodies. He was discharged after improving with intravenous immunoglobulin and other treatments.

Clinical characteristics of overlapping syndrome in patients with GFAP-IgG and MOG-IgG: a case series of 8 patients and literature review

OBJECTIVE

The overlapping syndrome of anti-GFAP and anti-MOG antibodies is extremely rare. This retrospective study reports 8 adult cases of the GFAP-MOG overlapping syndrome.

METHODS

We reviewed the clinical characteristics of 8 adult patients with the GFAP-MOG overlapping syndrome from Jan 2019 and Sep 2023 at the Third Affiliated Hospital, Sun Yat-sen University. Moreover, we searched the literature and included all case reports with this overlapping syndrome since 2018 on PubMed.

RESULTS

The predominant clinical syndrome was meningoencephalomyelitis (5/8), followed by meningoencephalitis (2/8), and myelitis (1/8). Five patients had a flu-like prodromal symptom or diarrhea. No neoplasms were found in these patients. Regarding brain MRI, T2-weighted/fluid-attenuated inversion recovery hyperintensities were in 7 patients and leptomeningeal enhancement was in 4 patients. However, only one patient had periventricular radial linear enhancement. Besides, two patients had large space-occupying lesions. For spinal MRI, T2-hyperintensities were observed in 4 patients, in which 3 patients had longitudinally extensive lesions. All patients were treated with immunotherapy, the median follow-up period was 18 months (range, 3-36 months). Three patients presented relapses during the follow-up, but all cases recovered to mRS scores ≤ 2 at last follow-up. In addition, we also reviewed 14 cases (including 7 adults and 7 children) with this overlapping syndrome by literature review.

CONCLUSION

Our findings provide data to understand the clinical features and prognosis of the GFAP-MOG overlapping syndrome. Recognizing this overlapping syndrome will expand our knowledge, allowing for better management of these patients.

MOG-antibody-associated transverse myelitis with the H-sign and unusual MRI enhancement: a case report and literature review

Transverse myelitis is the second most common symptoms in myelin oligodendrocyte antibody-associated diseases (MOGAD), causing obvious clinical manifestation. T2-hyperintense lesions mainly restricted to the gray matter in the spinal cord on axial magnetic resonance imaging, produce the H-sign, which is thought to be the typical finding of MOGAD. Contrast enhancement can be observed in some cases of myelin oligodendrocyte antibody-associated transverse myelitis (MOG-TM). However, reports on the enhancement pattern associated with the H-sign are rarely seen. In this report, we describe a case of pediatric MOG-TM in which the H-sign was observed without enhancement, while the surrounding white matter exhibited enhancement. This pattern contradicts the previously observed gray matter involvement. Then we reviewed the literatures of myelin oligodendrocyte antibody-positive myelitis to focus on the neuroimaging features and discuss the implications of our finding.

Aggressive Course of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD): An Illustration of Two Cases and Review of Literature

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a central nervous system demyelinating disease that has become a major source of morbidity among children and adults. In the first case, we present an 18-year-old Hispanic female with a recently resolved upper respiratory infection who presented with fever, headache, progressive quadriparesis, urinary retention, and encephalopathy. The hospital course involved autonomic dysfunction and prolonged intubation requiring tracheostomy and gastrostomy. Cerebrospinal fluid (CSF) showed pleocytosis and a positive MOG titer (1:40). Magnetic resonance imaging (MRI) showed longitudinally extensive cervicothoracic T2 hyperintensity and brain multifocal T2 hyperintensities. After high-dose intravenous methylprednisolone (IVMP) and intravenous immunoglobulin (IVIG), she had full neurological recovery by the last follow-up. The second case is of a 22-year-old Hispanic male who presented with progressive lower extremity paresthesia and weakness over six weeks. CSF demonstrated pleocytosis, elevated protein, oligoclonal bands, and MOG antibody. MRI revealed multiple subcortical T2-hyperintense lesions and enhancing midcervical and lower thoracic lesions. Treatment with IVMP led to minor improvement with discharge on steroid taper and azathioprine. The patient's disease progressed with a fluctuating course requiring two readmissions with upper extremity weakness, right optic neuritis, and urinary sphincteric dysfunction with neuroradiologic worsening. Treatment throughout multiple admissions included intravenous steroids, IVIG, plasmapheresis, mycophenolate mofetil, and rituximab with minimal improvement, symptom recurrence, and progression of multifocal lesions. The patient died four months after the symptom onset. These cases had markedly different treatment responses despite similar baseline characteristics. The difference in morbidity and disability burden highlights the importance of further investigation of this condition through clinical trials.

Clinical features of adult patients with positive NMDAR-IgG coexisting with MOG-IgG

INTRODUCTION

This study was designed to analyze clinical and radiographic features of adult patients coexisting with NMDAR-IgG and MOG-IgG.

METHODS

Eleven adult patients coexisting with NMDAR-IgG and MOG-IgG were collected from Xiangya Hospital, Central South University, between June 2017 and December 2021. Fifty-five patients with anti-NMDAR encephalitis and 49 with MOG-AD were served as controls.

RESULTS

Onset age was 27 (IQR 20-34) years old. Seizures and psychotic symptoms were prominent symptoms. Ten of eleven patients presented abnormal T2/FLAIR hyperintensity, mainly involving the cortex, brainstem, and optic nerve. Compared with the NMDAR IgG ( +)/MOG IgG ( -) group, the NMDAR IgG ( +)/MOG IgG ( +) group showed more ataxia symptoms (27.3% vs. 3.6%, P = 0.037), while more T2/FLAIR hyperintensity lesions were found in the brainstem (54.5% vs. 7.3%, P < 0.001) and optic nerve (27.3% vs. 1.8%, P = 0.011) with more abnormal MRI patterns (90.9% vs. 41.8%, P = 0.003). In comparison with the NMDAR IgG ( -)/MOG IgG ( +) group, the NMDAR IgG ( +)/MOG IgG ( +) group had more seizures (72.7% vs. 24.5%, P = 0.007) and mental symptoms (45.5% vs. 0, P < 0.001). The NMDAR IgG ( +)/MOG IgG ( +) group tended to be treated with corticosteroids alone (63.6% vs. 20.0%, P = 0.009), more prone to recur (36.5% vs. 7.3%, P = 0.028) and lower mRS score (P = 0.036) at the last follow-up than pure anti-NMDAR encephalitis.

CONCLUSION

The symptoms of the NMDAR IgG ( +)/MOG IgG ( +) group were more similar to anti-NMDAR encephalitis, while MRI patterns overlapped more with MOG-AD. Detecting both NMDAR-IgG and MOG-IgG maybe warranted in patients with atypical encephalitis symptoms and demyelinating lesions in infratentorial regions.

Enhanced and cross-reactive in vitro memory B cell response against Epstein-Barr virus nuclear antigen 1 in multiple sclerosis

Multiple sclerosis (MS) is a prototypical autoimmune disease of the central nervous system (CNS). In addition to CD4+ T cells, memory B cells are now recognized as a critical cell type in the disease. This is underlined by the fact that the best-characterized environmental risk factor for MS is the Epstein-Barr virus (EBV), which can infect and persist in memory B cells throughout life. Several studies have identified changes in anti-EBV immunity in patients with MS. Examples include elevated titers of anti-EBV nuclear antigen 1 (EBNA1) antibodies, interactions of these with the MS-associated HLA-DR15 haplotype, and molecular mimicry with MS autoantigens like myelin basic protein (MBP), anoctamin-2 (ANO2), glial cell adhesion molecule (GlialCAM), and alpha-crystallin B (CRYAB). In this study, we employ a simple in vitro assay to examine the memory B cell antibody repertoire in MS patients and healthy controls. We replicate previous serological data from MS patients demonstrating an increased secretion of anti-EBNA1380-641 IgG in cell culture supernatants, as well as a positive correlation of these levels with autoantibodies against GlialCAM262-416 and ANO21-275. For EBNA1380-641 and ANO21-275, we provide additional evidence suggesting antibody cross-reactivity between the two targets. Further, we show that two efficacious MS treatments - natalizumab (NAT) and autologous hematopoietic stem cell transplantation (aHSCT) - are associated with distinct changes in the EBNA1-directed B cell response and that these alterations can be attributed to the unique mechanisms of action of these therapies. Using an in vitro system, our study confirms MS-associated changes in the anti-EBNA1 memory B cell response, EBNA1380-641 antibody cross-reactivity with ANO21-275, and reveals treatment-associated changes in the immunoglobulin repertoire in MS.

MOG Antibody Disease: Nuances in Presentation, Diagnosis, and Management

PURPOSE OF REVIEW

Myelin oligodendrocyte glycoprotein antibody disease (MOGAD) is a distinct neuroinflammatory condition characterized by attacks of optic neuritis, transverse myelitis, and other demyelinating events. Though it can mimic multiple sclerosis and neuromyelitis optica spectrum disorder, distinct clinical and radiologic features which can discriminate these conditions are now recognized. This review highlights recent advances in our understanding of clinical manifestations, diagnosis, and treatment of MOGAD.

RECENT FINDINGS

Studies have identified subtleties of common clinical attacks and identified more rare phenotypes, including cerebral cortical encephalitis, which have broadened our understanding of the clinicoradiologic spectrum of MOGAD and culminated in the recent publication of proposed diagnostic criteria with a familiar construction to those diagnosing other neuroinflammatory conditions. These criteria, in combination with advances in antibody testing, should simultaneously lead to wider recognition and reduced incidence of misdiagnosis. In addition, recent observational studies have raised new questions about when to treat MOGAD chronically, and with which agent. MOGAD pathophysiology informs some of the relatively unique clinical and radiologic features which have come to define this condition, and similarly has implications for diagnosis and management. Further prospective studies and the first clinical trials of therapeutic options will answer several remaining questions about the peculiarities of this condition.

Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease Complicated by Pachymeningitis: A Case Report

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a rare autoimmune disorder that primarily affects the central nervous system (CNS). We present a unique case of MOGAD complicated by pachymeningitis, which is characterized by inflammation of the dura mater. The clinical presentation included vertigo, nausea, and vomiting. A diagnostic workup confirmed MOGAD complicated by pachymeningitis. This case underscores the diverse clinical manifestations of MOGAD and highlights the challenges in diagnosis and management, particularly when complicated by rare manifestations like pachymeningitis.

Joint radiomics and spatial distribution model for MRI-based discrimination of multiple sclerosis, neuromyelitis optica spectrum disorder, and myelin-oligodendrocyte-glycoprotein-IgG-associated disorder

OBJECTIVE

To develop a discrimination pipeline concerning both radiomics and spatial distribution features of brain lesions for discrimination of multiple sclerosis (MS), aquaporin-4-IgG-seropositive neuromyelitis optica spectrum disorder (NMOSD), and myelin-oligodendrocyte-glycoprotein-IgG-associated disorder (MOGAD).

METHODS

Hyperintensity T2 lesions were delineated in 212 brain MRI scans of MS (n = 63), NMOSD (n = 87), and MOGAD (n = 45) patients. To avoid the effect of fixed training/test dataset sampling when developing machine learning models, patients were allocated into 4 sub-groups for cross-validation. For each scan, 351 radiomics and 27 spatial distribution features were extracted. Three models, i.e., multi-lesion radiomics, spatial distribution, and joint models, were constructed using random forest and logistic regression algorithms for differentiating: MS from the others (MS models) and MOGAD from NMOSD (MOG-NMO models), respectively. Then, the joint models were combined with demographic characteristics (i.e., age and sex) to create MS and MOG-NMO discriminators, respectively, based on which a three-disease discrimination pipeline was generated and compared with radiologists.

RESULTS

For classification of both MS-others and MOG-NMO, the joint models performed better than radiomics or spatial distribution model solely. The MS discriminator achieved AUC = 0.909 ± 0.027 and bias-corrected C-index = 0.909 ± 0.027, and the MOG-NMO discriminator achieved AUC = 0.880 ± 0.064 and bias-corrected C-index = 0.883 ± 0.068. The three-disease discrimination pipeline differentiated MS, NMOSD, and MOGAD patients with 75.0% accuracy, prominently outperforming the three radiologists (47.6%, 56.6%, and 66.0%).

CONCLUSIONS

The proposed pipeline integrating multi-lesion radiomics and spatial distribution features could effectively differentiate MS, NMOSD, and MOGAD.

CLINICAL RELEVANCE STATEMENT

The discrimination pipeline merging both radiomics and spatial distribution features of brain lesions may facilitate the differential diagnoses of multiple sclerosis, neuromyelitis optica spectrum disorder, and myelin-oligodendrocyte-glycoprotein-IgG-associated disorder.

KEY POINTS

• Our study introduces an approach by combining radiomics and spatial distribution models. • The joint model exhibited superior performance in distinguishing multiple sclerosis from aquaporin-4-IgG-seropositive neuromyelitis optica spectrum disorder and myelin-oligodendrocyte-glycoprotein-IgG-associated disorder as well as discriminating the latter two diseases. • The three-disease discrimination pipeline showcased remarkable accuracy, surpassing the performance of experienced radiologists, highlighting its potential as a valuable diagnostic tool.